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Tuberculosis Part two: Treatments and cures

Published: 6 February 2024

During the early decades of the 19th century, cases of tuberculosis (TB) rose dramatically across much of Europe and North America. Urban living and factory working were ideal conditions for the disease and there was a heavy cost – particularly among young adults. Unfortunately, better treatments did not progress at the same rate. 

Remarking on this failure, Scottish Surgeon James Clark (1788-1870) felt that was “no reason to believe the physicians of the present day more successful than their predecessors were ten, nay twenty centuries ago."

Early Treatments

Advert for Parker’s Tonic, one of several popular ‘over the counter’ preparations that falsely claimed to cure consumption, 1870s.

Some of the advances in chemistry of this period were applied in combination with more traditional herbal remedies, but any effects were largely soothing rather than curative. Whether taking pills of copper sulphate, creosote and morphine or inhaling the vapours of turpentine, hemlock or tar, the medical treatments prescribed had little effect on the progress of the disease. 

Despite these treatment limitations, hospitals dedicated to diseases of the chest were among the places of care established during the 19th century, through charitable and philanthropic funding. In practice, they largely dealt with cases of pulmonary tuberculosis. The Hospital for Consumption and Diseases of the Chest, later the Royal Brompton Hospital and the Infirmary for Asthma, Consumption and other Diseases of the Lungs, later the Royal Chest Hospital were among those provided for patients with active TB. But while various medications and even massage could be employed, in the early years of such institutions, treatment was usually focussed around bedrest and good diets.

The Hospital for Consumption and Diseases of the Chest, London. Engraving c1845.

As observed by James Clark, such treatments echoed those of the Ancient Greeks and Romans. And those old observations about how the fresh air of mountains and coasts could bring benefits would find physical form in an institution that came to epitomise the care of TB patients until well into the 20th century – the sanatorium.

Sanatoriums

Although not solely used for TB cases, sanatoriums are inextricably linked to the disease. Their origins lie in long held beliefs about the benefits a ‘change of air’ could have for those with the disease. As it was also observed that TB was an uncommon disease in mountain communities, some of the earliest sanatoriums were established in the European Alps. Others appeared in remote coastal areas. Often large institutions, they accommodated patients for months or even years. Ideally, the end of a patient’s stay was when the disease went into remission – but many individuals never reached that point and were still residents when succumbed to the disease.

During the second half of the 19th century, their numbers expanded massively across Europe, North America and beyond. As they did so, they moved from being the preserve of wealthy paying guests to being the primary means of treatment for rich and poor alike. Funded through a variety of sources, some developed into very organised communities, generating funds through on-site factories and workshops and providing close-knit social lives for their patients. They also became a means to control and quarantine infectious individuals away from the general population.   

Not all sanatoriums were purpose built. Sometimes a wing of an existing hospital was converted for the purpose, but typically they had large windows, bright interiors and spacious terraces. Such designs allowed for rest, sunlight, fresh air and moderate exercise. A domestic alternative to the sanatorium also became available via the ‘TB hut’. Built to accommodate one person, rows of these small wooden buildings were already a feature of some sanatoriums. Similar designs became available to rent, borrow or buy and they could be set up in the garden of the family home. Many were designed with a rotating base so that the occupant could follow the sun during daylight hours. 

Treatments in sanatoriums were not always gentle. Some surgeons felt that a resting lung was more likely to heal, so they developed a number of different procedures to partially collapse a diseased lung and allow it to rest. More successfully, a less invasive approach known as ‘artificial pneumothorax’ produced the same effect and the level of improvement seen in some patients led to it becoming a standard therapy in the first half of the 20th century.

A cure for TB didn’t arrive until after the Second World War, but for many patients consigned to sanatoriums before then, their disease might at least go into remission. This allowed them to return to normal life, although their TB was always liable to return.  Sometimes a spell in a sanatorium could be beneficial in other ways. One of the last generation of sanatorium patients was Beatles' drummer Ringo Starr, who contracted TB as a teenager. During his two years in a sanatorium he started playing on some percussion instruments provided to help while away the time… and his love of drumming was born.

Sanatoriums

Light therapy

Exposure to sunlight was central to the sanatorium movement’s ethos, but capturing and focussing ‘natural’ light also provided a genuinely successful treatment for one unpleasant form of TB – the skin-disfiguring lupus vulgaris. Niels Ryberg Finsen (1860-1904), was a Faroese scientist who proposed that light could have positive medical and health benefits. Through experimentation he found that bacteria could be killed by ultraviolet light, whether emitted naturally from the sun or via artificial lighting. Putting his ideas into practice, Finsen developed a powerful artificial light system that focussed a strong beam on to small areas of skin. Patients with lupus vulgaris were the subjects of his first therapeutic experiments, with very positive results. Using what became known as Finsen lamps, trained nursing staff could treat several patients at a time and his technique was widely adopted. In 1903 Finsen received the Nobel Prize for his invention.

Finsen lamp being used for treatment of lupus vulgaris, early 1900s. Science Museum Group
Finsen lamp being used for treatment of lupus vulgaris, early 1900s.

Finsen's work opened the field to further research into light therapy and its applications. In the same era he was developing ultraviolet lamps, another form of electromagnetic radiation was being discovered – X-rays. Their use in relation to tuberculosis would have a profound effect on diagnosing the disease in the 20th century.

One of four lenses from the Finsen ultraviolet lamp Science Museum Group
Detail of a Finsen lamp lens.

Diagnosing TB with X-rays

X-ray imaging is not a foolproof method for diagnosing tuberculosis but once scientists showed it could reveal the lung damage TB can cause, sometimes before any symptoms occurred, it became central to managing the disease. Public health strategies were developed that encouraged large swathes of the population to have their chests X-rayed during regular mass screening campaigns. These began in the 1930s and carried through until the 1960s. 

Public awareness was vital for effective campaigns and a variety of media was employed to encourage individuals to be screened. The venues for mass screenings could be existing health facilities but taking X-rays to the people – wherever they may be – was central to their success and a variety of vehicles were employed to do it. X-ray technology could be bulky, but in Britain after the Second World War, a technique known as Mass Miniature Radiography was introduced. As the name suggests it used more compact equipment which allowed even more mobility. Over the course of this screening era, railway carriages, buses and aeroplanes were among vehicles specially kitted out, but in a variety of forms, the ‘X-ray van’ was the mainstay. These mobile units travelled into communities, visiting factories, community halls and schools to reach as many people as possible.

Before the Second World War, individuals diagnosed with active disease were likely to be transferred to a sanatorium. However, in the years after the war, the circumstances changed as a new treatment became widely available. While TB cases revealed by X-rays might still mean a spell in a sanatorium, once there patients could now finally be given a cure – antibiotics. But the first steps towards this achievement had been made in the previous century.

X-rays

Identifying the bacteria and stopping the spread

In the later decades of the 1800s there were major advances in our understanding of infectious diseases, their causes and how they were spread. In 1865, French physician Jean-Antoine Villemin showed that TB was contagious, rather than a hereditary disease – as many had thought. His work was largely overlooked at the time, but in 1882, German scientist Robert Koch announced his discovery of Mycobacterium tuberculosis, the bacteria that causes TB. Koch also developed a staining method that could reveal the bacteria in a patient’s sputum. 

The realisation that tuberculosis was contagious and spread via coughs and sneezes resulted in new public health strategies. Spitting in public became prohibited and even subject to fines in many countries. Signs warning about the practice became commonplace while spittoons, a then familiar sight in many public areas, were largely either removed or part-filled with an antiseptic. Those with active TB were encouraged to carry their own personal and sealable spittoons, if needed. 

Another result of this new understanding was that those with TB were viewed differently. They became people to keep away from. Many lost their jobs due to the fears about their condition and they might even be ostracised by their families. Inevitably, an active infection became something people would avoid revealing for as long as they could.

Stopping the spread

Following many years of research, a vaccine against TB did emerge, with French scientists Albert Calmette and Camille Guérin administering the first BCG (Bacillus Calmette–Guérin) vaccine in 1921. However, despite a century of use, some scientists have doubted its efficacy, particularly against the commonest form of the disease, pulmonary tuberculosis, which affects the lungs. In many countries, it remains a routine vaccine of childhood, but some have removed it from their schedule and others – such as the United States – have never used it routinely.   

Koch himself promoted what he claimed to be a cure in 1890. Tuberculin, a chemical extract from Mycobacterium tuberculosis, was initially received with enthusiasm. But within a year doubts were being expressed about its efficacy and hopes for an effective cure faded. Re-purposed, the tuberculin skin test later became the standard means to diagnose the presence of tuberculosis. It involves administering a small amount of tuberculin under the skin and measuring the body’s reaction to it. Those who’ve been exposed to the bacteria develop red bumps at the site.  Further tests reveal if the infection is active or latent.   

The major treatment breakthrough happened in 1943 when research, primarily by scientists Selman Waksman, Elizabeth Bugie and Albert Schatz, led to the development of the antibiotic streptomycin. A second antibiotic, Para-aminosalicylic acid (PAS) was discovered the following year. These drugs inhibited the ability of the tuberculosis-causing bacteria to multiply but their rapid uptake for TB and other diseases, resulted in bacteria strains that were resistant to the antibiotic. Fortunately, in an era of medical advances, researchers found that TB could be most effectively treated with drugs used in combination. Such an approach reduced the likelihood of resistance developing. In the two decades after the discovery of streptomycin, a number of other drugs emerged to become established in the first line of defence against TB, namely isoniazid, pyrazinamide, ethambutol and rifampicin.

Eradicating tuberculosis?

Countless lives that would have been lost to TB have been saved since the arrival of antibiotics, but drug-resistant strains of the bacteria pose a major ongoing challenge. They emerge due to spontaneous gene mutations in the bacteria that causes the disease. But the misuse or mismanagement of antibiotics can result in an increased likelihood of such resistance developing. This could be down to patients not finishing their course of treatment, wrong doses being given, unreliable supplies or the drugs being of sub-standard quality. Levels of resistance can vary. When infections are resistant to the two most commonly used antibiotics for tuberculosis it’s referred to ‘multi-drug resistance’ or MDR-TB. When there’s also further resistance to the second line of antibiotics, it’s known as ‘extensive drug resistance’ or XDR-TB. 

The situation can be even more serious when those infected with TB already have other health issues. Individuals with HIV (human immunodeficiency virus) – the virus that can lead to the development of AIDS – are especially vulnerable. The two diseases can work in tandem as HIV reduces a body’s immunity which can allow tuberculosis to progress. Even with the arrival of improved therapies for HIV patients, the risk of TB remains high and it is still a major cause of death for those living with HIV. Some researchers have also suggested that the presence of an HIV infection also raises the risk of multi- and extensive drug resistance. 

Tuberculous meningitis Science Museum Group
Magnified brain tissue of an HIV-positive patient with tuberculous meningitis. The density of Mycobacterium tuberculosis (red rods) is much higher than it would be in non-HIV patients.

Despite the phenomenon of drug resistance, the Word Health Organisation (WHO) aims to end the global TB epidemic by 2035. This follows earlier strategies that successfully produced a downward trend in annual case numbers. By 2035 the WHO wants to see a reduction of over 80% in new cases and of at least 90% in deaths, with the ultimate aim being a world free from tuberculosis by 2050. Such efforts were not helped by the arrival of another disease – COVID-19. As a result, both the reductions in TB case numbers and deaths were knocked back behind schedule. 

The long painful story of our relationship with tuberculosis still has a way to play out. In 2022 over 10 million new cases were recorded globally and there were over 1 million deaths, with more than 10% of those dying also having HIV. The vast majority of cases were in low and middle income regions of South-East Asia, Africa and the Western Pacific. As well as the impact of the COVID-19 pandemic, poverty, conflict and inequalities in access to health services are all factors in this ongoing human cost. But with the ambitions of the WHO and other organisations, promising vaccine candidates undergoing trials and new therapies being researched there might finally be an ending in sight.