1940-1970: The decline and return of tuberculosis

By the 1940s there were a variety of antibiotics that allowed physicians to control most cases of tuberculosis. For patients that seek medical attention and follow the prescription of their physician, tuberculosis can be controlled and even cured. By 1969 it seemed that the disease had been conquered, and attention was diverted from it.

It seems to be normal for human beings to forget that of which they do not see. When we don't have a war for a while, we tend to assume one will never occur again and we cut our military spending. When a war occurs, we usually aren't prepared. The same can be said of disease. When we go years without a plague, we assume the disease is cured. When the plague strikes, we aren't prepared. A perfect example of this is the Spanish Flu of 1918.  

There was a friend of mine who often said that we ought to have a war every ten years so we don't forget that freedom comes with a price. We should have a plague every so often so that we don't take these diseases for granted. Surely we don't want wars or plagues, but my friend had a valid point.

By the 1930s and 40s sulfa drugs and antibiotics were discovered as a means of treating infection. These and other medicines allowed physicians to effectively treat and even cure tuberculosis. This decade saw a rapid decline in the number of tuberculosis patients.  

According to Elaine Landau, in her 1995 book "Tuberculosis:"

As late as 1969, the federal government was still channeling annually more than $20 million in TB project grants to local clinics and hospitals throughout the nation. But the declining TB rate made people feel that the crisis was over. So when the government began giving blocks of aid to states and municipalities to be used at the areas' discretion, the funding generally was not expended for TB controll. 

As time passed,countless successful TB programs were dismantled. In New York City alone, more than one thousand beds formerly reserved for TB patients were eliminated from municipal hospitals. Although outpatient services were supposed to be established to ensure the disease's continued decline, these were never made available. Instead, funding was diverted to meet more immediate needs. As one physician who's treated numerous TB victims described the situation, "We knew how to cure it. We had it in our hands. But we dropped the ball. (1, page 3, 4)

Once the "ball was dropped" it was difficult to pick it up again. Organizations with the ability to provide methods of preventing the spread of such diseases, such as the Centers for Disease Control and Prevention (CDC), were not provided with enough funds to effectively perform this task. (1, page 34)

In 1989 a plan was made to provide the CDC with $30 to $34 million dollars to create a TB control plan. Yet the plan was never made "because each year that it was proposed, the White House eliminated its funding from the budget." A similar plan was proposed in 1993 to offer $484 million for TB prevention, but the budget was cut by the Clinton administration to $124 million before it was sent to Congress. So the return of a disease that once ravaged a nation was greatly ignored by Reagan, Bush and Clinton. (1, page 35)

What may have opened the eyes of the government was the AIDS epidemic that struck during the 1980s. Studies showed that with weakened immune systems, up to 50 percent of AIDS victims were developing tuberculosis, and were unable to fight it off. This is one reason tuberculosis spread through prisons and homeless shelters rather fast, particularly in cities like New York "where nearly one-fifth of prison inmates have TB, but none of the jails have separately ventilated cells for contagious cases." (1, page 35-37)

To make matters worse the TB bacteria has the ability to mutate to create drug resistant strains. This occurs when people who are given antibiotics, which are proven to cure TB if used properly, were not taking the antibiotics once they started feeling better. Effective treatment usually takes 6-9 months, but many would stop taking it within weeks.

Landau also said that "this is actually worse than not taking any medication at all, because over a period of time the illness no longer responds to any form of medication, and they have, in fact, dissipated the drug's effectiveness... Unfortunately, significant numbers of people have misused their medication this way. The tendency to do so appears to cut across racial, class, and economic lines." (1, page 39)

Studies show that up to 50 percent of TB patients do not take their medicine as prescribed, and that 14.1 percent of TB cases responded poorly to TB medicines. Studies also showed that TB resistant strains have a 50 percent mortality rate. (1, page 39-40)

References:

1. Landau, Elaine, "Tuberculosis," 1995, New York, Chicago, London, Toronto and Sydney, Franklin Watts 

1840-1903: Open air treatment for consumption

Figure 1 -1899, National Jewish Hospital, TB patients treated with sunlight (4)

Around the turn of the 20th century tuberculosis was a common ailment, and a leading cause of death.  Yet it also lead to a general feeling of gloom among the populace, especially considering little was known about it and there was no cure.  Yet if you had it there was hope, thanks to places like sanatoriums and hospitals like National Jewish Hospital for Consumptives in Denver Colorado.

In the 1840s Hermann Brehmer (1826-1889) was diagnosed with the condition and he told his doctor he might benefit from the open air of the Himalayas.  He also decided there might be benefits from isolating tuberculosis patients from the rest of the community, so he created hydrotherapy institution in Gorbesdorf, which is a village in Silesia, Germany. 

Bre

At first he had trouble convincing the medical community he was on the right track, but ultimately he became so successful that various sanatoriums opened in mountainous areas all over Europe and the United States.  One famous one in the United States was built in Denver, Colorado in 1899 by the Jewish Community. 

Many of the Jewish Community who were struck with tuberculosis were flocking to the Denver area because of it's fresh, dry, mountainous air.  Yet many of these victims were without enough money to be able to afford food or housing.

This was brought to the attention of Frances Wishbart Jacobs who worked hard to raise money to build shelter for these destitute victims of consumption.  She was able to find support from members of the Jewish Community and then to generate enough money to build an institution.  (1)

National Jewish Hospital 1892

In 1892 Jacobs died, and a year later the building was finished.  Yet the country was also mired in a recessions that year prompted by the silver crisis, and this resulted in a lack of funds to open the facility.  The building laid empty until Rabbi William S. Friedman took up a project to complete and open the institution.  (2)

The doors to the National Jewish Hospital for Consumptives opened in 1899 with the motto: "None may enter who can pay -- none can pay who enter." (1)  While it was originally built by the Jewish Community, anyone was allowed to enter who needed help.  (2)

One of the original therapies for tuberculosis patients in Denver was to receive heliotherapy, which was sunlight therapy (See figure 1).  It was believed that sunlight would help them "combat the disease."  (3)  This type of therapy, along with open air therapy altogether, was supported by Thomas Beddoes (1803-49), who performed many tests on respiratory patients, and Herrmann Brehmer (1826-89), who, as noted, opened the first sanitorium.  (3, page 37)

Figure 4 -- Open air therapy for TB patient at his home (3, page 38)

Studies were also done that showed TB patients recover faster in the winter than summer months.  In fact, "Dr. Otto Walther says he not infrequently had an inch of snow on his blankets.  At some localities tents are the only shelter, but whether the patients are housed in cottages or in tents, the free access of air must be absolute and uninterrupted. Drafts are not feared. At night the windows, which should constitute at least one side of the room or ward, are kept open; in some places the sashes are removed altogether; the sides of the tents are rolled up, except in the severest storms. In very cold weather the head and hands may be protected with woolen cap and gloves, and at all times the patients are well provided with blankets. In summer the beds or reclining chairs are moved into the open or into covered porches during the day; for the winter most places are provided with glass porches or sun parlors; where the patients spend their days in bed or reclining in steamer chair." (3, page 38)

(5, page 44)

The benefits of open air therapy as reported were: (3, page 39)

• Reduction of the fever
• Improvement of the appetite,
• Induction of sleep

As noted, "Cough and night-sweats disappear in a short time, and, as a logical consequence, the medicinal treatment is reduced to a minimum. Antipyretic drugs are never used and expectorants are rarely required. Suralimentation (the belief that consumption could be cured by forcing them to eat) is practised in many places, especially in the German resorts, where it is pushed to an almost incredible degree; even bed patients with considerable pyrexia are placed on a full diet of meat and vegetables. Trudeau and Flick * content themselves with giving their patients three full meals a day, allowing them to drink milk between meals if they have a desire for it; when, however, there is anorexia, the patient is given raw eggs beaten up with milk every two or three hours." (3, page 39)

While open air treatment was utilized "judiciously" and based on "individual cases," the therapy could also be recommended for home use as well. (See figure 4) Patients may also benefit from treatment in tents, walks or rides in the open air.  (3, page 39)

Another type of therapy was pulmonary gymnastics, or exercise.  While this was debated as an effective therapy, it was often recommended at the various sanatoriums.

In 1895 a German by the name of Wilhelm Konrad von Roentgen discovered the x-ray that allowed doctors to see the disease in its early as well as it's late stages.  This marked the first time that the disease could be diagnosed in its early stages instead of having to wait to see the late signs.  It also allowed doctors to see the tubercles in those who had survived the disease.  It showed both active and inactive tuberculosis.

References:

1. Gurock, Jeffrey S., ed., "American Jewish History," 1998, New York, vol. 3, part 3, pages 1095-6
2. "The History of National Jewish," NationalJewish.org, http://www.nationaljewish.org/about/whynjh/history/
3. Tissier, Pneumotherapy
4. Photo compliments of National Jewish Health, Facebook, http://www.facebook.com/photo.php?fbid=10151140094301092&set=a.140185801091.110191.41885201091&type=1&theater, accessed on 10/20/12
5. Picture from the Journal of the Outdoor Life," National Tuberculosis Association, Volume XI, January, 1914, 10 cents an issue or $1.00 a year

1876: Colorado cures hay fever

Dr. George Beard lists the above approximate altitudes above sea level for
various areas of Colorado, stating that such high altitudes benefit people
suffering from hay fever and asthma. 

In the mid 19th century it was discovered, perhaps by mere accident, that higher altitudes present themselves to easier breathing. I already covered how tuberculosis patients benefited from sanatoriums set up in Denver, Colorado, and how later these TB sanatoriums were converted to asthma hospitals.  Yet did you know that hay fever sufferers also found relief in the centennial state.  

Vacationing to the State of Colorado was actually recommended as a remedy for hay fever in an 1876 book "Hay-fever; or, Summer Catarrh," by George Beard, president of the American Hay Fever Association.  He wrote that:

In 1873 a pamphlet was issued under the indorsement of the Medical Association of Denver, Colorado, giving details of over one hundred cases of ordinary asthma and hay-fever that had been cured, or more or less benefited, by residence in or near that region. The Committee of Asthmatics, who represented the Asthma Association, state in their report that probably not one half or one quarter of those in Colorado responded to the call for information. They state, furthermore, that the amount of sunshine there is remarkable; from July, 1872, to December 29, 1873, there were but three days (excepting perhaps in June, 1873) when the sun was not seen.

Dr. Henry K. Steele, President of the Medical Association, in a brief report, states that "in the opinion of the above medical association the climate of Colorado, in and about the range of the Rocky Mountains, has a wonderful curative power over asthma; that nearly all such patients coming into this climate are relieved—at least so long as they remain here; and that all, if not entirely relieved, are sooner or later benefited, with the exception of those cases dependent on or complicated with organic disease of the heart or lungs.

 Dr. O. M. Bryan, of Colorado, writes: "I have known a few cases temporarily relieved by visiting Colorado. Persons suffering from hay-asthma are generally relieved soon after crossing the Missouri River. My opinion is that ninetynine cases out of every one hundred would be relieved, or cured for the time being, by visiting the Rocky Mountains. (1, page 151-153)

It's just interesting to note the various studies and reports confirming the benefits of breathing the cool, sunny air of Colorado, or similar places.

Reference:

1.  Beard, George M, "Hay-fever; or, Summer Catarrh," 1876, New York, Harper and Brothers, Publishers, pages 151-153

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1860: Villemin's asthma theories ignored

Jean Antoine Villemin (1827-1892)

Most people of the civilized world were aware of a killer by the name of consumption, although no one knew where it came from nor what to do about it.  If you caught it you probably going to die. Fear of this killer created a feeling of doom and gloom that spread across Europe and the United States.

After obtaining his medical degree from Stassburg in 1853, Jean Antoine Villemin was sent to Val de Grace, the military school at Paris, for further study.  While a professor at Val de Grace he made the observation that men living in close quarters in barracks were most likely to catch the disease. So he set out to perform an experiment.  (1)(2, page 664)

Villemin obtained some tissue from a man who died of tuberculosis, and he inoculated it into rabbits.  He knew the rabbits were probably going to die, although he knew that he could save the lives of millions of people around the world if his experiment succeeded.  

Every day he checked on his rabbits, and by the third month his diligence paid dividends, as he observed tuberculosis lesions.  He published the results of his study, and they were ignored by the medical community.  By respecting his experiments physicians could have limited the spread of one of the most dreadful diseases ever to inflict mankind, yet their ignorance prevented them from doing so.

Villemin's work would ultimately be proven true by other scientists.  Yet until that time, Villemin worked overtime trying to convince the medical community that he was correct.  He would ultimately become a hero, although that time wouldn't arrive for several more years.  

By his investigations into the lungs, he was able to learn about other diseases as well, including asthma.  In 1860, he tried to disprove the nervous theory of asthma with his own scientific experiments, which were described by Dr. J. B. Berkart in 1878: 

Villemin professed to have demonstrated the pathological changes that deprived the pulmonary tissue of its elasticity, and predisposed the bronchial mucous membrane to hypersemia. He stated that emphysema originated in a proliferation of the inter-capillary nuclei, whose advancing growth tended to compress the alveolar vessels. As the nutrition of the air-vesicles became impaired, they were unable to efficiently perform expiration. At the same time, the respiratory surface was reduced, and the blood accumulated in the bronchi to such extent as to convert their mucous membrane into a kind of erectile tissue. This condition gave rise to no symptoms, either subjective or objective. Its existence became manifest only by the readiness with which trifling incidents produced their effect. Hyperaemia (inflammation?) rapidly ensued, and led to the dyspnoeal attacks that other writers consider as nervous asthma. The chronic inflammation of the alveoli, described by Villemin, is, however, not recognised by other observersIronically, 130 years later, asthma was found to be a disease of chronic inflammation. Should we go back now and give Villemin cretic in retrospect? (3, pages 33-34)

Like his tuberculosis theory, his asthma theory was ignored by the medical community. This was because the nervous theory was so popular at this time that there was no room for any other theory.  Villemin was yet another victim of how hard it is to change the minds of people who are already set in their ways. 

However, in the decades that followed Villemin's publication of his work on tuberculosis, the works of Louis Pasteur and Robert Koch would force the medical community to look at Villimin's work and accept it as fact.

Further reading:

• 1855:  Traube doubts nervous theory of asthma

References:

1. "Jean Antoine Villemin," britannica.com, http://www.britannica.com/EBchecked/topic/629218/Jean-Antoine-Villemin, accessed 3/3/14
2. Garrison, Fielding Hudson, "An introduction to the history of medicine," 3rd edition, 1821, Philadelphia and London, W.B. Saunders Company
3. Berkart, J.B., "On Asthma: It's pathology and treatment," 1878, London, J. & A. Churchill
4. "Obituary: Jean Antoine Villemin," The British Medical Journal, Nov. 13, 1892, 1860:  Villemin's asthma theories ignored, accessed 3/3/14

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1835: Ramadge's inhaling tube for consumption and asthma

Figure 1 -- Ramadge Iinhaling Pipe (1, page 93)

Respiratory therapists are well aware of insentive spirometers (IS) and positive end expiratory (PEP) therapy. You might think these are modern inventnions. You would be wrong.

Incentive Spirometers are small, hand held devices that that encourage patients who are on pain medicine, or who had recent abdominal or chest surgery, to take deep breath and cough to facilitate movement of secretions, thereby preventing or treating atelectasis and pneumonia. The incentive spirometer was invented in 1970 by R.H. Bartlett and quickly became an inexpensive mode of bedside therapy.

PEP therapy involves having the patient blow through a resistor that applies resistance, or positive pressure (usually 10-20 cwp), during expiration. The pressure acts as a splint to keep otherwise collapsible terminal airways and alveoli open. This facilitates the movement of secretions that would otherwise be trapped due to airway closure. It was invented in Denmark during the 1970s and was became popular in Scandanavia, Denmark and Canada before making its way to the United States. (5, page 1001)

So both IS and PEP therapy were invented during the 1970s and are forms of chest physiotherapy, or chest exercise through manual movement. However, the general concept was conceived of back in 1810 by a doctor by the name of Francis Ramadge.

He was a student of Rene Laennec, the inventor of the stethoscope.  The two men worked together in order to find a means of preventing people from developing consumption, the most common respiratory disease at that time.

Laennec suggested a natural cure for consumption was the formation of cicatrizations, or scar tissue, following the softening of the tubercles.  This scar tissue, he suspected, acted as a natural barrier against the disease. He suspected most people living with the disease had such scar tissue.

Ramadge, on the other hand, believed that since consumption resulted in a small, contracted and frail rib cage, anything causing the opposite effect prevented consumption. Various other physicians agreed with Ramadge. (1, pages 91- 93)  (3, page 8-9, 37)

Two such diseases suspected as acting as natural barriers against the disease, Ramadge suspected, were catarrh (colds) and asthma. He said:

For instance, let us begin with catarrh. Here tumefaction (swelling) of the mucous membrane preventing the free egress of the air, imprisons it in the air-cells, and produces a quasi emphysematous state of the lungs, expanding their entire volume to a certain degree, and pushing outwards in every direction the walls of the chest. Asthma also acts in a similar way. (3, page 8)

They believed if patients took care of their asthma this would act as a barrier to consumption. Ramadge said that this was one of the "ulterior good" effects of having asthma. It was "a lesser evil being substituted for a greater." (6, page 37)(1, pages 91- 93) (3, page 9, 37)

Ramadge also believed that any medical condition that impeded free expiration tended to "mitigate and arrest the disease."  Such conditions included: enlarged tonsils, tumors pointing towards the pharynx, polyps in the nasal passages, aneurysms of the aorta, diseases of the heart, obstruction of the liver, hysteria and pregnancy.  (3, page 8)

It was based on these theories that he invented what was called "an inhaling pipe," which would later be referred to as the Ramadge Inhaling Pipe.  He believed that by inhaling and exhaling through the pipe the patient would develop an expanded chest. In this way, regular use of the pipe had "palliatve and prophylactic, as well as a curative, intentions." (1, page 93) (3, page 10, 59)

It was a pipe with hot tar stuffed into it that you inhaled for therapeutic means. The tar, and the narrow diameter of the tube, provided resistance to inspiration and expiration, and this was supposed to provide "gymnastics" or "exercise" for the consumptive patients.

The Ramadge Inhaling Pipe wasn't exactly PEP therapy, but the principle was similar.  He said:

The value of the tube in catarrh, which it supersedes as a curative agent, must not be overlooked. By due exercise and expansion of the bronchial ramifications, it contributes to allay, or indispose to, irritability of the lining membrane, and I have often heard patients state that after its use in the morning they have been better, and more freely able to bring up the accumulated phlegm. (3, page 59)

The inhaling pipe wasn't an IS, although it worked similarly to encourage deep breathing and coughing.

Ramadge said:

The lungs may simply and safely be kept in daily exercise, and expansion to the full amount may be effected by atmospheric inhalation, through the respiratory apparatus. (3, page 15)

Dr. Samuel Sheldon Fitch, in his 1847 book "Six lectures on the uses of the lungs," described the tube.  He said: (1, page 91-93)

This tube he at first made about four and a half feet long, with an opening through its whole length, provided with a mouth-piece to go between the lips, and the patient sucked in, or inhaled the air as long as he could, and then through the same tube, blew it out again. By this process, the chest would rapidly enlarge. Dr. Eamadge also made an inhaling tube a little like a whistle, with a valve in it so constructed that the air would go into the mouth and lungs through a large free passage, and on returning, the air would be forced to go outmof the mouth and lungs through a much smaller opening. The effect of which is, to allow the lungs to fill rapidly and without exhaustion of strength, and on leaving the lungs, it is all passed through an opening not much larger than a knitting- needle, by which the air was slowly forced out of the lungs, and by this pressure the lungs were greatly expanded, and the air every where opened the chest in the largest manner. (1, page 93)

Fitch said the tubes were made of wood or ivory, although he recommended they be made of gold, platina or silver so that they last long, and the patient can take the tube wherever he goes and can use it often to keep his lungs expanded.  (1,2)

Ramadge said he'd prefer his patients use the inhaling tube...

...but, in the absence of the inhaler, I have no hesitation in saying, on the Principle of choosing the minor of two evils, that exposure to the exciting causes of catarrh, under prudent restrictions, is an alternative that may be judiciously adopted in consumption. (3, page 15)

Surely there were other remedies for consumption, such as leeches, tonics, sedatives and relocation, but...

...The use of the inhaling tube I consider to be essential in the treatment of phthisis; indeed, all other treatment is comparatively secondary and ancillary. (3, page 10)

He said it worked even as a last ditch effort to save the life of a consmptive in the dire states of the disease.  He said:

It may be thrown out as a sheet-anchor, even at the eleventh hour. A clergyman's daughter, who had been despaired of, in phthisis, by several medical men, was induced, as a dernier ressort,to employ the inhaling apparatus for two or three months, during which period a decided retrogression of all her bad symptoms was established. Considering herself well, she left it off and died. It is not improbable that, had she gone on till her disease had been more completely brought. (3, page 59) 

While recommended for consumptive patients, he said his inhaling device also worked well for asthmatics.  He said:

In asthma the windpipe is too small for the volume of the lungs, and, though it may seem contradictory, the mechanical respiration by the tube has the effect of restoring this disturbed relation to its healthy standard. The objection to it, on the score that asthma is liable to be superinduced by its use, arises from idle prejudice. Could I but present one-tenth part of the cases which have been rescued from a premature grave, chiefly by means of using this instrument, I should force irresistible conviction on the most incredulous, or at least induce them to institute a number of experiments, patiently and judiciously, so as to satisfy themselves of the truth. (2, page 10)

Not sold yet as to the efficacy of the Ramadge inhalaing pipe?  Well, how about some endorsements that might change your mind.  Ramadge said:

This mode of treatment has many advocates, both in England and abroad. Lebeau, physician to the King of the Belgians, and senior surgeon of the Military Hospital at Brussels, as also Hohnbaum, physician to the Duke of Saxe Meiningen, and a distinguished pathologist, highly approve of it. Among the American medical men might be mentioned, the names of Drs. Pitch, Newton, and Hull, of Philadelphia, and several other distinguished practitioners of the same country, together with a great many continental physicians, all of whom have adopted its use, and are its zealous supporters. (3, page 11) 

Ramadge would go on to become a well respected physician who specialized in pulmonary disease, ultimately becoming senior physician to the Infirmary for Asthma, Consumption, and other diseases of the Lungs. He claimed to have had the advantage of over 30,000 cases of consumption in all its various stages. He said:

I have no hesitation in asserting -- in contradiction to the opinion of many medical practitioners -- that this disease when properly, judiciously, and skillfully treated, is a curable as any other disease, the curability of which is not dispute. (1, page iv)

The Ramadge Tube was recommended by physicians for pulmonary gymnastics and as a prophylactic therapy for consumption until better devices were invented at the turn of the next century. (4, page 228)

Further reading:

• 1819: Laennec says consumption can be cured
• 1910: Early PEP and Incentive Spirometers

References:

1. Fitch, Samuel Sheldon, "Six lectures on the uses of the lungs," 1847, New York, H. Carlisle, pages 91-93, 
2. Laennec, Rene, "On Mediate Auscultation," 1827, London, T and G Underwood.  
3. Ramadge, Francis Hopkins, "The Curability of Consumption: the reprint of a series of papers, presenting its most prominent and important practical points in the diagnosis, prognosis, and treatment of the disease," 1850, London, Printed by W. Clowes and Sons
4. Tissier,Paul Lewis Alexandre, edited by Solomon Solis Cohen, "Pneumotherapy: Including Aerotherapy and inhalation methods," volume X, 1903, Philadelphia, P. Blakiston's Sons and Co., pages 227-230.  If the profession of respiratory therapy existed in their era, we would be reading their books.  However, as it was, their books were written for the medical profession.  For a more detailed description of any of the devices mentioned on this blog click on the links provided. Unless otherwise indicated, all material from this post was from Tissier's book. 
5. Sehlin, et al, "Physiological Responses to Positive Expiratory Pressure Breathing:A Comparison of the PEP Bottle and the PEP Mask,"  Respiratory Care, August, 2007, Vol. 52, No. 8, pages 1000-1005

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1819: Laennec says consumption can be cured

Dr. Rene Laennec might have become interested in diseases of the lungs because his own mother died of tuberculosis when he was only five-years-old.  Of course it may simply have been his desire to help people who lived under the gloomy cloud created by the grim diagnosis of the disease.

While he specialized in diseases of the chest, he would end up spending more time studying consumption than any other disease, perhaps becoming the first to describe the disease as curable. (1, page 6)

He referred to it as pthhisis pulmonalis in his 1919 book "Mediate Auscultation," dedicating three full chapters to the disease.  He said it results in the development of "species of accidental production" called the tubercle in the lungs. (2, page 283)

He said the ancients described an "accidental production" as any abnormality, and used the term "tubercle" to describe an accidental production in the lungs, such as a cyst or cancerous growth, that resulted in phthisis or wasting away.  (2, page 283, 310)

Laennec, however, recommended tubercle only be used to describe tubercles of consumptive patients. (2, page 283)

He described the tubercle:

Whatever be the form under which the tuberculous matter is developed, it presents at first the appearance of a grey semi-transparent substance, which gradually becomes yellow, opaque, and very dense. Afterwards it softens, and gradually acquires a fluidity nearly equal to that of pus; it being then expelled through the bronchi, cavities are left, vulgarly known by the name of ulcers of the lungs, but which I shall designate tuberculous excavations. (2, page 285)

He said in most cases the disease results in extreme emaciation, which is why the ancient Greeks referred to it as phthisis, wasting away.  (2, page 304)

He said the internal organs other than the lungs are usually of normal length, but of lessor diameter.  The chest is "usually narrow and sometimes evidently contracted." The skin is usually very pallid and pale.  (2, page 306)

He said:

"The emaciation then makes rapid progress toward complete marasmus (severe malnutrition).... The nose becomes sharp and drawn; the cheeks are prominent and red, -- and appear redder by contrast with the surrounding paleness; the conjunctiva of the eyes is of a shining white or with a shade of pearl blue; the cheeks are hollow; the lips are retracted, and seem moulded into a bitter smile; the neck is oblique and impeded in its movements; the shoulder blades are projecting and winged; the ribs become prominent, and the intercostal spaces sink in, particularly on the upper and fore parts of the chest. Sometimes even the whole chest seems contracted...; and this may actually be the case, particularly when the disease is very chronic, owing to the contraction and tendency to cicatrization of large tuberculous excavations. The belly is flat and retracted; the larger joints and those of the fingers, appear enlarged from the falling away of the neighboring soft parts; and even the nails become incurvated, in consequence of the absorption of the pulpy extremities of the fingers. No other disease gives rise to so complete emaciation as phthisis,—except cancer and continued fever of long duration. (2 page 372)

The patient sometimes complains of a "guggling sound," which Laennec attributes to the softening the the tubercles.  This is often expectorated, resulting in sputum similar to that produced during a fit of common catarrh. (2, pages 375-377)

The disease generally presented with obvious signs and symptoms.  The earliest symptom was a dry cough, which may be confused with dry catarrh. Haemoptysis, fever, chills and night sweats are other prominent symptoms. Some patients are known to require a change of sheets several times in a night. (2, pages 369-272)

Most people, including most physicians, during the early 19th century had a very gloomy view of this disease, as most who were diagnosed with it perished as a result of it.  The medical prognosis, therefore, was not very good.  (2, pages 319-320)

However, Laennec explained that the ancients believed "phthisis" started as a result of chronic inflammation, and they probably came to this conclusion because an early symptom of the disease is a slight dry cough that could easily be contributed to a dry catarrh (common cold). (2, page 319, 320, 369)

This chronic inflammation resulted in the gradual formation of pus in pulmonary tissue.  They believed this was curable, especially in the early stages. (2, pages 319-320)

This was pretty much the common perception of phthisis all the way up to the late 19th century when pathological anatomists discovered tubercles in the lungs of patients with phthisis.  (2, page 369)

Yet once physicians started studying pathological anatomy, they learned that this was not true, that once one developed tubercles (like cancer) the prognosis was poor, with death almost certainly imminent. (2, pages 319-320)

Laennec seemed to disagree with this notion, believing instead that, while the disease was not curable during the early stages of the disease, it was curable in the latter stages, that is, he said, "after the softening of the tubercles and the formation of an ulcerous excavation."  (2, page 321)

He said:

The formation of the semi-cartilaginous membrane on the surface of tuberculous excavations, must be considered, in my opinion, as a curative effort of nature. When completely formed, it constitutes a sort of internal cicatrix (a scar of a healed wound) analogous to a fistula, and is, in many cases, not more injurious to health than this species of morbid affection. All the persons whose cases I noticed above, died of diseases not referable to the pulmonary organs. They had all lived a greater or less number of years in a very supportable state of health, being merely subject to chronic catarrh. Some indeed had more or less of dyspnoea, but without any fever or emaciation. (2, pages 321-322)

Essentially, he believed that early on in the disease the tubercles were soft, and these were not curable. However, later in the disease scar tissue formed, either by fistula or cicatrix.  This hardened tissue acts as a natural barrier against the disease. (2, page 336)

While essentially cured, the patient may still present with symptoms. Generally, he believed those cured by fistula developed a chronic catarrh occasioned with sputum production that was sometimes copious; and those cured by cicatrix developed a dry cough that was not frequent, not severe, and not much of an inconvenience to the patient. (3, page 337)

He even gave examples of patients cured of consumption.

In a lady, formerly a patient of M. Bayle, fourteen years since, and whose case was decidedly consumption, (as appears from M. Bayle's notes in her possession,) the sign of pectoriloquy (particular lung sound made by a tubercle) is most distinct. This lady recovered beyond all expectation; she is now stout, and the only symptom she has at all referable to the lungs, is a slight cough. I have no doubt that the cartilaginous excavations above described exist in this person's lungs.

In July of 1817 he attended to a lady of 48 who had been in good health until the age of 30 when she became subject to severe attacks of catarrh and became quite emaciated.  Upon assessment he observed her breathing was diminished over the upper right chest.  By this, and by the appearance of her sputum, he diagnosed her with tubercles in the early stages.  As the treatment he applied leeches and more.  (2, pages 325-326)

Her symptoms were unchanged until February of 1818 when her cough increasingly distressing with thick yellow sputum.  He said:

I did not see the patient during this attack, which she looked upon as a cold; but I visited her in the beginning of April, and upon examining her chest I found most distinct pectoriloquy at the anterior and upper part of the right side. I was convinced by this that the supposed catarrh (the cold) had been the discharge of the softened tuberculous matter. The sound of respiration was good over the whole chest; and even in the vicinity of the pectoriloquous spot; the pulse was not frequent and the heat moderate. On this account I entertained hopes of her recovery, and prescribed ass's milk. The cough and expectoration progressively lessened, the flesh and strength returned; and, in the beginning of July, my patient had regained every appearance of the most perfect health. (2, page 326)

The pectoriloquy continued, although he suspected that it would, offering proof that she had suffered and survived a bout of consumption.  (2, page 322)

Laennec listed hundreds of various remedies used by the ancients and moderns, and he said any of these are worthy of trying, so long as the patient tolerates them, and this included bleeding with leeches and cautery by the application of caustic potass on several locations of the body.

The medicinal list also included a long list of expectorants, purgatives, etc.  It also included the inhalation of fumes, air of cow houses, oxygen, hydrogen, etc. (for a longer list of Laennec's remedies check out my post 1819: Laennec remedies for consumption.

The remedy he was most fond of, however, was change of situation.  (2, page 392)

Laennec said that the ancients observed that consumption was sometimes cured by the seaside, and that they often recommended sailing to their phthisical patients. He said Areteaus recommended sailing and the air of the seashore, Celsus recommended a voyage to Egypt.  (2, pages 243-394)

This was an idea recently picked up by English physicians, who often sent their phthisis patients to Maderia.   (2, page 343)

There was one case early on in his career, long before he had invented the stethoscope, whereby a patient of his was diagnosed by both himself and Dr. Bayle as having chronic catarrh.  However, upon a change of air, or a move to the seaside, he was cured.

Several years later, and after he had use of the stethoscope, he had another opportunity to assess this patient.  He said:

Since then I have had an opportunity of satisfying myself, by means of the stethoscope, that our patient had had more than a mere catarrh. His respiration is quite perfect throughout the whole chest, except at the top of the right lung, in which point it is totally wanting. On this account, I am certain that this portion of lung had been the seat of an ulcerous excavation, and that this had been replaced by a complete and solid cicatrice. The health of this gentleman continues good, although he has often occasion to speak in public. He has sometimes a little dry cough, on the change of weather, but takes cold very seldom. (2, page 340)

Yet while medicine may offer benefits to the consumptive, it does not offer a cure. The only means to a cure, he said, was nature.  (2, page 396)

So while he began his career under the belief there was no cure for consumption, his own experience and assessment skills proved that this was not always the case. He learned that there was a cure for consumption...

...or at least, for such a suspension of their symptoms as may be deemed almost equal to a cure, as the individuals may enjoy such a state of health as may enable them to fulfill all the duties of civil life, for several years, or until a fresh development of tubercles produces a fresh and final seizure. (2, page 337-338)

Patients who were thus "cured" might still have some symptoms, such as episodes of catarrh or a cough, but may otherwise "live in a supportable state of health." Others may have dyspnea, but without the fever and emaciation. (2, page 322)

As one final note to this discussion, Laennec said:

My experience leads me to deem such cases to be extremely common: those related above occurred to me in the course of some months: and I have since met with many others. (2, page 340)

Laennec was, therefore, among the first physicians of his era to speculate that consumption was a curable disease.  This subject would be further investigated by his pupil, Francis Ramadge.

It was perhaps due to his passion to learn about this disease that cost him his own life.  He would end up one of the many victims of consumption at the young age of 45.

References:

1. Ramadge, Francis Hopkins, "The Curability of Consumption: the reprint of a series of papers, presenting its most prominent and important practical points in the diagnosis, prognosis, and treatment of the disease," 1850, London, Printed by W. Clowes and Sons
2. Laennec, Rene, "Mediate Auscultation," translated by John Forbes, Notes by professor Andral, 4th edition, 1838, New York, Samuel S. and William Wood

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1819: Laennec describes causes of consumption

In 1819, when he wrote his book, "Mediate Auscultation," Dr. Rene Laennec, of France, had no idea that consumption, or what he referred to as phthisis pulmonalis and what we refer to as tuberculosis, was caused by a bacteria.  So, as with other physicians of his era, he was force to speculate based on his studies and own observations.

Some things he suspected as causing tuberculosis were:

1.  Cold:  It was more common in northern Europe and America where the temperature has a tendency to become cold.  It is less common in southern Europe and between the tropics.  In places where it is cold year long, such as high up in the Alps, people tend to prepare for cold weather better with warm clothing and houses. (1, page 341)

2.  Too light clothing:  This may give the impression of cold, particularly in young women whose disease typically begins with pulmonary catarrh, pneumony, or pleurisy.  (1, page 342-343)

3.  Locality: It is more common in large cities than in small ones, and more frequent in small cities than in the country. It was less common on the seashore than inland.  Sailing, or a long voyage at sea, tends to offer as a cure.  (1, page 343-344)

4.  Haemoptysis:  Many physicians suspected this cause inflammation that resulted in congestion of the vessels, leading to blood in the lungs.  However, Laennec wasn't convinced, suspecting the blood was a result of the tubercles in the lungs.  (1, pages 345-347)

5.  Depressing passions: Strong and long lasting passions, such as grief, tend to not only cause consumption, but cancers and other accidental productions as well.  He said people in the city are likely to come into contact with more people, "and is in itself a cause of more frequent and deeper vexation." Plus, in the city, people are more prone to be witness "the greater prevalence of immortality... a constant source of disappointment and misery." (1, page 347)

6.  Fevers:  Severe continue or intermittent fevers are a common cause of phthisis.

7.  Infected people:  A question Laennec postulated was: is consumption contagious?  He said it had long been suspected to be contagious, although he had seen many cases of people living together with a consumptive who did not themselves succumb to the disease.  Still, he said, the common people still suspect it is a contagious disease

While the exact cause may have eluded him, he was aware that, while Hippocrates suspected phthisis attacked people between the ages of 18-35, and Bayle suspected it attacked people between the ages of 40-40, Laennec believed that "no age was exempt from it." (1, page 352)

He did, however, believe women were more subject to it than men.  (1, page 353)

References

1. Laennec, Rene Theophile Hyacinthe, "A treaties on the diseases of the chest, and on mediate auscultation," tranlated by John Forbes, 1838, New York, Philadelphia, Samuel S. and William Wood, Thomas Cowperthwaite and Company

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1819: Laennec remedies for consumption

Consumption was the most common disease seen by physicians during the 19th century.  Rene Laennec, in his 1819 book "Mediate Auscultation," gives us a list of common remedies during his time.

He said bleeding was a common remedy for consumption, although he believed it was neither a cure nor a preventative for the disease, and doing so only results in a "useless loss of strength."  (2, pages 387-388)

However, Laennec did support the application of leeches in the upper part of the thighs. (2, pages 387-388)

He described the use of issues and cautery by the ancients.  He said:

Hippocrates directed four eschars with a red hot iron below the axilla, on the breast or back.  Celsus recommends six -- one beneath the chin, one on the throat, one under each nipple, and one at the lower angle of each scapula.  (2, page 388)

However, Laennec said he...

...repeated the application of the searing iron as many as twelve or fifteen times.  It is, however, only a very small number of patients that will submit to a mode of treatment so horribly painful. Small moxas, of only a line in diameter, applied two or three at a time, and repeatedly, have appeared to me more useful than the searing iron; as under their employment I have sometimes se'en a very striking suspension of all the symptoms. At all events, I have now almost entirely renounced the use of the actual cautery. Measures so painful ought not to be had recourse to, unless they are found by experience to hold out a reasonable hope of success. For this reason, I now restrict myself to the application of the caustic potass, in the places above mentioned, so as to form eschars of eight or ten lines in diameter; and I do not even insist upon this, if the patient is very averse to it. (2, pages 388-389)

To promote expectoration, he recommends: (2, pages 389-390)

• Lime-water
• The natural and artificial sulphureous lime-water
• Natural and artificial sulphureous
• Hydrochlorate of lime
• Preparations of mercury
• Hydrochlorate of barytes
• Preparations of antimony (2, pages 389-390)

To cause the cicatrizing of the internal ulcers, a physician might try: (2, page 390)

• Plants of an anticorbutic and aromatic kind
• Purgatives
• Balsamics, particularly the balsams of Tolu, Peru, and Mecca
• Terpentine
• Camphor
• Sulphur dissolved in volatile oils
• Vapors from decoctions of plants of an emollient, aromatic, narcotic, or balsamic kind
• The fumes of different kinds of resins burned on a hot iron or a brazier, particularly of myrrh, benzoin, and petrolium tar
• The air of cow houses
• The air produced by the sublimation of zinc, lead, sulphur, etc. 
• Inspiration of gases such as oxygen, hydrogen, 
• Etc. (2, page 390-391) 

All of these above were generally thought to provide benefit to the consumptive by one physician or another since the days of Hippocrates.  Laennec said:

I shall content myself with merely enumerating several others, the inefficacy of which has been sufficiently demonstrated. Of this kind are— mercurial salivation; emetics frequently repeated, or continued for a long period in doses sufficient to excite nausea merely; acorns, roasted or raw; charcoal; different kinds of mushrooms, and among others, the boletus suaveolens and the agaricus pifratus and deliciosus ;red cabbage; crabs, oysters, and other shell-fish; frogs; vipers; chocolate; the conserve and sugar of roses in large doses; wine and spirits; sudorifics; electricity; millepedes; opium; cicuta; wolfsbane; cinchona; the seeds of the phellandrium aquaticum; the preparations of lead; hydrocyanic acid; the swing, formerly recommended by Themison (apud Csel: Aurel.) and revived by the moderns, &c. &c.

For those whose consumption was not curable, he offered various palliative treatments.

Emollient drinks, and alimentary matters of a mucilaginous nature, have been always in use,—such as milk, (woman's, ass's, cow's, goat's, mare's,) saloop, sago, gum, Iceland moss, potato-starch, arrow-root, barley, rice, sugar, and the infusions of inert mucilaginous plants, properly sweetened. When the cough is dry, and the expectoration difficult, also when there is a want of sleep, opium in small doses, or any other narcotic extract, is added with advantage. The hydrocyanic acid also sometimes succeeds very well in relieving the cough and even the dyspnoea; but its effects are less certain than those of opium. Antimonials, although at different times much cried up, have never appeared to me of great efficacy, even in aiding expectoration. The diarrhoea must be also treated by mucilaginous drinks, and the milder preparations of opium. However, when it depends on the presence of tuberculous ulcers in the intestines, as it almost always does, we can only hope at best to suspend its violence; and we cannot always even effect this. The acetate of lead appears sometimes to moderate this symptom; but it is much more efficacious in lessening the perspirations: indeed it is almost the only means we can oppose to these. Dyspnoea must be combated by the preparations of opium and other narcotic plants. The hydrocyanic acid and musk are also sometimes beneficial in this respect. I speak not here of pulmonary congestions, whether terminating in inflammation, haemorrhage, or serous effusion. I shall merely remark, that, in these cases, we must not take away more blood than is absolutely necessary to relieve the symptoms, since bleedings, either too copious or too frequent, have an evident effect in accelerating the progress of the disease. (1, page 395)

However, while all of these could be trialed by a physician, the one remedy he found to be most useful was that of relocation.  He said this was a trend the English recently picked up, and which he found to be quite effective, particularly relocation to the seaside, or a voyage at sea.   (1, pages 243-394)

References:

1. Ramadge, Francis Hopkins, "The Curability of Consumption: the reprint of a series of papers, presenting its most prominent and important practical points in the diagnosis, prognosis, and treatment of the disease," 1850, London, Printed by W. Clowes and Sons

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1750-1850: Tuberculosis wreaks havoc

The industrial revolution swept across the civilized world from 1750-1850. New inventions improved agriculture, manufacturing, mining, transportation and technology, and this had a stunning effect on culture and economies.  The world was forever changed for the better, or so people suspected.

Yet while culture and economies improved, a vicious killer spread across this modern world.  No one knew what it was. No one knew where it came from.  No one knew what to do about it.  The killer was generally referred to as consumption, and if you got it you were probably doomed. 

Yet since people were ignorant about what it was, and what caused it, and how it was contacted, they didn't know that by getting together in poorly ventilated areas of mills and factories that they were breathing the contaminated air that was exhaled by people who had the disease.  They didn't know it was caused by a bacteria, and that the bacteria was transported through the air and was inhaled.  

They didn't know the disease was spread by sharing hanker chiefs, and by touching contaminated people.  They didn't know the disease was prevalent before the industrial revolution, but the disease was more of a random disease that occurred here and there by chance.

Yet with the beginning of the revolution, people gathered in small, poorly ventilated areas.  People moved to cities, right into the grasp of the killer.  They did this because they wanted to create a better life for themselves and their children, and they did this not knowing they were moving into the closed chambers of the rampant and killer beast that consumption was.

There were a variety of names for it. It was called scrofula (swollen lymph nodes), Pott's disease (TB of the bone, spine), the Great White plague (17th century Europe), consumption or phthisis (TB of the lung), lupis vulgaris (TB of the skin), Mesenteric disease (TB from non-pasteurized milk), white swelling (TB of bone), and King's Evil (TB of of lymph glands). Or sometimes it's simply referred to as "captain of the ship of death" or "captain of men and death. Later on it would become known as tuberculosis. (9) 

A plague swept through Europe in the 16th century, and during this time what Hippocrates referred to as phthsis was referred to as the Great White Plague. Yet it was usually described by scientists and physicians as either phthsis or consumption and sometimes even scrofula.
During the next 200 years thousands would be killed. Little was known about it other than it's symptoms. Usually, a patient was diagnosed by a physician only after the patient noticed he was coughing up blood. By this time the disease was near its later stages, and prognosis was grim.
Franciscus dele Bo Sylvius published a book in 1679 called the Opera Medica in which he made the association between nodules in the lungs with phthisis. Perhaps as a result, in the 17th and 18th centuries, there were many references to the disease being contagious, and many warnings about those infected with it. (3) 

Yet for the most part physicians thought it was hereditary, as which was no different from what Hippocrates thought way back in the 5th century B.C.

Giovanni Baptista Morgagni, an Italian anatomist who lived 1682-1771, wrote quite a bit about medicine in his later years. He warned that the condition might be an infection and he warned against doing autopsies on anyone infected with it. (1, page 2)

TB was called "White Plague"
in the 18th-19th centuries

Right around the turn of the 17th century a health edict in the Republic of Lucca in Italy warned:

"Henceforth, human health should no longer be endangered by objects remaining after the death of a consumptive. The names of the deceased should be reported to the authorities, and measures taken for disinfection.”(2)

English Physician Benjamin Martin published a book in 1720 called "A New Theory of Consumption."  He wrote that the disease was caused by "wonderfully minute little creatures." He believed these "creatures" enter the body and cause the symptoms.

Likewise, Martin believed that those in close proximity to the patient, particularly those talking to the person, should be careful.  He wrote:

It may be therefore very likely that by an habitual lying in the same bed with a consumptive patient, constantly eating and drinking with him, or by very frequently conversing so nearly as to draw in part of the breath he emits from the lungs, a consumption may be caught by a sound person... I imagine that slightly conversing with consumptive patients is seldom or never sufficient to catch the disease."

In 1793, Dr. Matthew Ballie published a book "Morbid Anatomy of Some of the Most Important Parts of the Human Body." (?check year and book) He provided a description of the lungs and many lung diseases. He wrote about consumption, and was among the first to note nodules in other organs other than the lungs.
In 1689 Richard Morton (1637-1698) used the term "tubercle" to describe lesions he saw in organs of those who died of consumption.

Rene Laennec was born in 1787 and contacted tuberculosis as a young adult. He became rapt in studying this disease during the course of his career as a physician. He is best known for his 1816 invention of the stethoscope.  He was also the first to master its use.  He was also the first to see tubercles in lung tissue of those patients?

In 1819 he published "A Treatise on Diseases of the Chest, and of Mediate Auscultation." He described how to use the stethoscope in assessing and diagnosing patients. He also discussed the pathology of many disease processes, including what was used it to describe symptoms during various stages of the condition.  He described the adventitious lung sounds heard in people infected with pulmonary diseases like consumption.

Laennec met his demise by the grips of tuberculosis in 1826 at the young age of 45.

Samuel George Morton (1637-1698) was a pupil of Laennec. In 1834 he published his own book titled "Pulmonary Consumption." This would be the first book on the subject published in the United States. (4, page 10). 

He recommended that the age old practice of bleeding patients who are coughing up blood was a "plan that has hurried thousands of patients to their graves by destroying the last remains of strength."

However, if the patient was of good strength with a good pulse, he recommended "ten or twelve ounces of blood, taken rapidly from a large orifice, may divert the current of the circulation and relieve the pulmonary congestion." (5, page 120).

He said this would work because the condition resulted in ulcers which dry and the blood becomes congested around these regions causing the ulcers to burst, and this is why these patients spit up blood. He believed bleeding prior to this happening would help prevent the congestion.
Other remedies may also help "promote absorption of the congested blood" Some of these include:

• Spirits of turpentine
• Elixir of vitriol
• Common salt
• Opium
• Sugar of lead
• Rest
• Diet of gum water and farinaceous food

He agreed with a Dr. Beddoes, who recommended a ride in the fresh air as treatment.  Morton quotes Beddoes:

"In haemoptysis and pulmonary hemorrhages, I never observed any bad consequence from traveling in a carriage: on the contrary, I have known these discharges to stop on a journey, though previously they had, for many days, occurred at least once in twenty-four hours."

Johan Lukas Schönlein (1793-1864) wrote relatively little during his life. However, he did write a doctoral thesis and two papers of 1 and 3 pages respectively.

Despite his lack of enthusiasm for writing, it was Schönlein who introduced the terms hemophilia and tuberculosis in 1839. The word "tuberculosis" was derived from "tubercle", a word introduced by Morton in 1689 to describe the characteristic lesions of consumption.

The mid 19th century was a time when many scientists and doctors were experimenting with microbes. In 1843 Dr. Klencke became the first to cause an animal to develop the condition by innoculating a rabit with "portions of miliary and infiltrating tubercles from a man. Klencke, after accomplilshing this result, did not continue his investigations, and they were consequently soon forgotten." (6)
Despite all the research that had been done prior to 1865, many physicians believed that each case of tuberculosis "rose spontaneously in predisposed people." (2) 

Yet it was in 1865 that a French military physician named Jean Antionne Villemin proved that tuberculosis was caused by an infecting organism.
He inoculated cattle with both human tuberculosis and bovine tuberculosis. (6)  He thus proved that the two diseases were of similar origin, and he proved that the disease could be transferred form a human to cattle and from cattle to rabbits.  (2)

Regardless of Villemin's work, the idea that tuberculosis was a spontaneous condition was ingrained in the minds of many medical experts who performed many experiments trying to prove Villemin wrong.  While it took several years, in the end Villemin's ideas won out.

Robert Koch (1843-1910) was the next to perform many experiments on tissue from tuberculosis victims to see if he could learn more about it and come up with a cure.  He invented a staining method that allowed him to see the tubercle bacillus.

Through "artificial cultivation" he was able to grow the bacillus.  He then proceeded to reproduce the characteristics of tuberculosis in animals.  He also identified different forms of the disease in various animals.

Slowly, as the deadliest disease in the history of mankind continued to wreak havoc, the civilized world was learning more about it.  It would remain one of the top causes of death in the United States and Europe until the 1930s, when all this wisdom would result in control of the beast.

References:

1. Norris, Charles Camblos, "Gynecological and Obstetrical Tuberculosis," 1921, New York, London
2. Koehler, Christopher W., "Consumption, the great killer," http://pubs.acs.org/subscribe/archive/mdd/v05/i02/html/02timeline.html
3. "History of TB," New Jersey Medical School, Global Tuberculosis Institute, http://www.umdnj.edu/ntbc/tbhistory.htm
4. Klebs, Arnold Carl, "Tuberculosis," 1909, New York
5. Morton, Samuel, "Pulmonary Consumption," 1834, Philadelphia
6. Flenner, Simon, , "Immunity in Tuberculosis," Annual report of the Smithonian Institution, 1907, New York, page 627 
7. "Captain of the Men of Death," Ulster Med J. 1989; 58(Suppl): 7–9.
8. Sigeris, Henry E, "A History of Medicine," volume I, "Primitive and Archaic Medicine," Second Edition, 1955, New York, Oxford University Press, page 53
9. Seth, Vimlesh, SK Kabra, Rachna Seth, "Essentials of Tuberculosis,"  Third ed., Jaypee Brothers Medical Publishing, 2006, page 3-4
10. Jones, Greta, "Ca;ptain of All These Men of Death," 2001, New York
11. Prioreschi, Plinio, "A History of Medicine," 1991, volume I, "Primitive and Ancient Medicine," Edwin Mellen Press, Chapter VII, "biblical Medicine," page 514
12. Landau, Elaine, "Tuberculosis," 1995, New York, Chicago, London, Sydney, Franklin Watts, pages 13-32

Photos:

• 1.  from  http://www.grantvillegazette.com/articles/The_White_Plague

Further reading:

• Essentials of tuberculosisi in children
• Johnson, H.A., "Consumption in the Northwestern States," The Chicago Medical Journal and Examiner, Volume 37, William M. Syford, et al, editors, 1878, pages 133-143

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