Tuberculosis in ancient times
In spite of an array of effective antibiotics, tuberculosis is still very common in developing countries where overcrowding, malnutrition and poor hygienic conditions prevail. Over the past 30 years associated HIV infection has worsened the situation by increasing the infection rate and mortality of tuberculosis. Of those diseases caused by a single organism only HIV causes more deaths internationally than tuberculosis. The tubercle bacillus probably first infected man in Neolithic times, and then via infected cattle, but the causative Mycobacteriacea have been in existence for 300 million years. Droplet infection is the most common way of acquiring tuberculosis, although ingestion (e.g. of infected cows’ milk) may occur. Tuberculosis probably originated in Africa. The earliest path gnomonic evidence of human tuberculosis in man was found in osteo-archaeological findings of bone tuberculosis (Pott’s disease of the spine) in the skeleton of anEgyptian priest from the 21st Dynasty (approximately 1 000 BC). Suggestive but not conclusiveevidence of tuberculotic lesions had been found in even earlier skeletons from Egypt and Europe. Medical hieroglyphics from ancient Egypt are silent on the disease, which could be tuberculosis,as do early Indian and Chinese writings. The Old Testament refers to the disease schachapeth, translated as phthisis in the Greek Septuagint. Although the Bible is not specific about this condition, tuberculosis is still called schachapeth in modern Hebrew. In pre-Hippocratic Greece Homer did not mention phthisis, a word meaning non-specific wasting of the body. However. Alexander of Tralles (6th century BC) seemed to narrow the concept down to a specific disease, and in the Hippocratic Corpus (5th-4th centuries BC) phthisis can be recognised as tuberculosis. It was predominantly a respiratory disease commonly seen and considered to be caused by an imbalance of bodily humours. It was commonest in autumn, winter and spring, tended to affect groups of people living close together, and young people in particular. Pregnancy exacerbated phthisis which was characterised by a chronic cough (worse at night), prominent sputum, often blood streaked and presumably arising from necrotic lung tissue. The face was typically flushed with sunken cheeks, sharp nose and very bright eyes. There was atrophy of all muscles with prominent (“winged”) shoulder blades, fever and perspiration often associated with shivering. Symptoms were described which would fit in with complicating lung abscess and empyema. Hippocrates also mentions disease entities which would fit in with extra-pulmonary tuberculosis, like Pott’s disease of the spine and cervical lymphadenopathy (scrofula), although he did not associate this with phthisis. Minimal specific therapy was prescribed. Subsequent writers in the Hellenistic and Roman eras added little to the classic Hippocratic clinical picture of phthisis, but Celsus (1st century AD) and Galen (2nd century) first suggested that it was a contagious condition. From Themison (1st century BC) onwards, therapeutic regimes became more drastic with the addition of inter alia strict dietary regimes, purges, enemas and venesection. Celsus suggested long sea voyages with ample relaxation and a change of climate. Aretaeus (1st century AD) stressed the importance of not exacerbating the suffering of people with chronic disease by imposing aggressive therapy. Except for the introduction of more drastic therapy the concept of phthisis (tuberculosis) had thus not progressed materially in the course of the millennium between Hippocrates and the end of the Roman era – and it would indeed remain virtually static for the next 1 000 years up to the Renaissance. There is, however, some evidence that the incidence of tuberculosis decreased during the major migration of nations which characterised the late Roman Empire.