MEDICAL MATTERS Tuberculosis (TB) has a sad but romantic history. X-rays of Egyptian mummies show the disease present thousands of years BC, writes Dr Charles Daly.
Think of the boy-king Edward VI dying of "consumption" at 16, or Keats dying in Rome at 26, having gone there in the mistaken belief that the warm weather would cure him. Chopin went to Majorca and Robert Louis Stevenson to the South Seas, for the same reason, with the same outcome. Think of the Brontes, writing in their desolate Yorkshire parsonage, all three sisters dying within six years of each other. George Orwell, desperately ill on the island of Jura, managed to finish 1984 before succumbing to TB.
In Ireland, even though the incidence was dropping because of better housing and general social conditions, TB was still a huge killer in the first half of the last century. Entire families were wiped out, strong young men and women were ravaged by "galloping consumption", and treating TB was an occupational hazard for medical staff (one chest physician, for self-preservation, was alleged to have instructed his patients to "cough towards nurse").
In the 1930s and 1940s, TB was the AIDS of its time. "Delicacy" was a euphemism for having TB. People would cross the street to avoid contact with a "delicate" person. Readers of Angela's Ashes may remember how Frank McCourt, as a delivery boy, had to deliver telegrams, because nobody else would, to a certain house where there was a "delicate" girl.
Those lucky enough to survive could find themselves affected in other ways as TB did not respect any part of the body. Destruction of bone was common with chronic abscesses and sinuses and hunchback formation. Pelvic TB was a common cause of female infertility. Cutaneous disease damaged facial features. Many had subclinical TB (a mild form without symptoms).
Almost no family in Ireland was unaffected. My aunt died of TB as a teenager, long before I was born. Another aunt survived, but spent a year in Blanchardstown in the 1950s getting chemotherapy, whiling away the tedious months making lampshades out of old X-ray films.
Treatment was almost non-existent. The wealthy went to sanatoria in Switzerland or to warm countries in the belief that cold air or Mediterranean sunshine was curative. Surgery such as inducing an artificial pneumothorax ("resting the lung") or partial pneumonectomy was of limited success. An experimental vaccine known as BCG was in the early stages of development but not yet widely available.
Than along came Dr Noel Browne, the sanatoria, streptomycin - the first successful anti-tuberculosis drug - and TB should have been well on the way to the annals of medical history. Unfortunately, this has not happened and TB hasn't gone away, you know.
Recent debate over the role of Peamount Hospital has highlighted the current status of TB in Ireland as a disease which is still present and changing its characteristics. While the incidence and mortality of TB is far less now, it is still enough to cause concern. In the Southern Health Board (Cork and Kerry), the number of cases of TB has increased from 72 in 2001 to 77 in 2002 and 95 last year. Neonatal BCG vaccination, which provides immunity in some 70 to 80 per cent of recipients, is routine everywhere in Ireland except Cork, although Dr Cathal Bredin, respiratory physician at Cork University Hospital, says most of the recent cases in Munster are in elderly, socially deprived Irish-born men.
The Peamount controversy centres on whether the appropriate place to treat new cases of TB is an acute general hospital or a specialised centre. There never has been a nationally designated TB treatment centre, even though Peamount de facto may have been such a place.
Acute general hospitals have enough troubles dealing with infections such as MRSA, an organism very difficult to eradicate, usually found in asymptomatic patients, and with endless potential to trouble severely ill patients and delay routine surgery. Acute pulmonary TB is highly infectious and these hospitals would prefer someone with drug-resistant TB to be treated elsewhere where isolation and barrier nursing is more easily achievable.
Uncomplicated TB is curable with chemotherapy using drugs such as isoniazid, ethambutol and rifampcin in varying combinations taken for six to nine months. This is usually initiated in hospital and once sputum is negative for TB bacilli, patients may continue treatment at home. However, compliance with treatment is vital: a casual or unreliable attitude to treatment may lead to the development of drug resistance, treatment failure and the need to use more hazardous or untried second- or third-line drugs.
TB still kills millions worldwide, mostly in the Third World, often in co-existence with AIDS. The tragedy is that many could be cured if resources were available. In the west, the demography has changed: no longer is it the killer of the flower of youth, but of the marginalised, the elderly and the socially deprived. Some of our new immigrants come from countries where public health systems are inefficient and this may represent a new reservoir of TB, especially of the drug-resistant variety. Whatever the location, patients with TB should continue to be treated appropriately and adequately: it is still a potential major health hazard, and we should no longer view its existence with complacency.