A moveable cough

Dr. Bob explains consumption and reassures a woman who put on the wrong shoes.

Published October 11, 1999 4:00PM (EDT)

I was reading "A Moveable Feast" and came across this passage: "He knew I knew he had the con, not the kind you con with but the kind you died of then and how bad it was, and he did not bother to have to cough, and I was grateful for this at the table. I was wondering if he ate the flat oysters in the same way the whores in Kansas City, who were marked for death and practically everything else, always wished to swallow semen as a sovereign remedy against the con; but I did not ask him ..." I assume by "con" he means consumption. Did women in the late 1800s or early 1900s believe that semen could cure consumption or anything else? And, as with most wives tales, there's usually a bit of truth. Here, too? Also, what is consumption? -- A curious reader

Think of the pale and fragile Camille ensconced on a chaise in a Victorian parlor, daintily coughing a small spot of blood onto her white lace pillow. Before "con" referred to politics, it described a syndrome of cough, fever, malaise and weight loss. (The body was being consumed, hence the word consumption.) Marked by long periods of suffering, slow deaths and occasional spontaneous remissions, with no apparent cause or cure, the disease was an ideal metaphor.

Personality traits were ascribed to sufferers, both in getting the illness and as a result of the illness. A certain languid artistic sensibility was considered a predisposition. Will, morality and virtue were considered methods of resistance. Folk cures were everywhere, though I confess to a lack of expertise in Hemingway's particular remedy. (It does sound like a great first date line in the days before consumption was known to be contagious. Now such a thought would be the kiss of death.)

Initially the syndrome was non-specific and included a variety of similar-appearing pulmonary disorders such as "miner's lung" (silicosis) and stonecutter's phthisis. In 1868 the organism mycobacterium tuberculosis was isolated and shown to be the underlying cause of most cases of consumption. Despite studies clearly demonstrating the ability to transfer the disease via blood and sputum from infected patients to rabbits, acceptance of the infectious nature of tuberculosis took more than another 14 years. Meanwhile, many physicians continued to preach that consumption was caused by breathing unhealthy air (miasmas), by bad living habits, even by moral turpitude. (Sound suspiciously like the early days of AIDS?)

In the pre-antibiotic era, treatment was symptomatic. Sanitarium rest cures became the standard. Drastic surgical procedures were developed, such as lung collapse/inserting talcum powder into the chest cavity to restrict lung movement. In the early '60s more powerful antibiotics became available. For the first time, TB seemed under control, destined for ancient history. As evidence of this, the TB ward I worked on during my internship in 1966 was closed in the early '70s. (No such decline occurred in third-world countries. The disease continued to flourish among the poor and malnourished.)

By 1985 the incidence of TB was on the rise. According to the Centers for Disease Control and Prevention in Atlanta, worldwide there are 8 million new cases and 3 million deaths annually. In 2000, the CDC estimates, the annual new infection rate will be 10 million. Tuberculosis is the leading cause of death attributable to a single infectious organism and the fourth largest overall cause of death worldwide. Presently 10 to 15 million people in America are infected, mainly in such high-risk populations as nursing homes, AIDS hospices, homeless shelters and prisons. Much of this increase has been a direct result of the worldwide AIDS epidemic, because it both increases susceptibility to new disease and allows for the reactivation of the latent form of TB (rejuvenation of dormant bacteria from a previously controlled infection). Decreased cellular immunity is the primary culprit.

People with normal immune systems have a much better chance of controlling and/or limiting their infection. The combination of M. tuberculosis and HIV infection is catastrophic, associated with higher death rates for each disease, a problem compounded by the emergence of single- and multi-drug resistant strains. While the number of new cases of tuberculosis for the United States is again on the decline, largely as a result of strenuous public health control measures, the numbers continue to rise in several states and the District of Columbia, where the disease remains at near epidemic levels.

The problem is compounded by shifts in world population. Forty percent of new TB cases in the United States last year occurred in foreign-born patients, up from 16 percent in 1982, according to the New York Times. Numbers are similar in most developed countries. World travel means world spread, including resistant organisms.

Sound scary? You bet. So, just how contagious is tuberculosis? An informed guess is that you have a 50 percent chance of contracting the disease from someone with active TB if you spend two months, 24 hours a day in close proximity or six months of eight-hour-a-day contact. A single casual exposure has a low risk. In a Washington University School of Medicine study of 5,000 medical school employees, there was an approximate 3 percent rate of infection (skin test conversion) annually. Yet researchers estimate that each person with active TB will go on to infect between nine and 12 others. In TB-ravaged Russia, it is estimated that a minimum of 3.5 million new drug-resistant cases will occur in the next year.

The point: TB is very definitely contagious. Reasonable precautions should be taken. As individuals we can observe good hygiene and "just say no." The single most preventable risk factor for TB is HIV disease. But the problem is more than personal hygiene. TB is a worldwide catastrophe and a serious comment on our times. We do not need to be rocket scientists to understand the following ingenious experiment; 130 years later, this study still says it all:

In 1870, shortly after the discovery of the tubercle bacillus, Edward Trudeau, a young New York physician suffering from advanced pulmonary tuberculosis, performed the following experiment: He infected groups of rabbits with tubercle bacilli and then housed them under different living conditions. A group of animals was infected with tubercle bacilli and kept in a dark, crowded box in an unheated cellar. As controls, a group of uninfected rabbits was also placed in a damp, dark pit with only minimal food and water. A third group was infected and released on a small island where they had plenty of food and exposure to fresh air and sunlight. When Trudeau examined his three groups of rabbits several months later, the results were indisputable. The infected rabbits that he kept in the cellar were all dead from TB. The uninfected rabbits living under the same conditions were emaciated but otherwise alive and well. Of the infected rabbits released to roam Rabbit Island, one died, but the other four were alive and with no autopsy evidence of active TB. His conclusion? Progress of a tuberculous infection could be arrested, even reversed, by a regimen of rest, good food, sunlight and fresh air. Trudeau established that poor housing and malnutrition were not, per se, a cause of tuberculosis, but provided a fertile breeding ground.

Sound familiar? Sound like the infectious disease version of the rat overcrowding experiments? With the recent politicization of debate on national health care, it is impossible not to wonder about priorities.

The metaphor has shifted -- TB is no longer about spiritual inadequacies leading to sighs and swoons and the slow ravages of consumption. The new metaphor is obvious; medicine may advance, but the bugs will continue to outsmart us. And maybe it is the bugs who are the reminders of virtue and morality. After all, TB's persistence is a measure of how we feel about the impoverishment of others. Remember the rabbit experiments.

Suggested reading: Mycobacterial Pathogenesis: A Historical Perspective by Frank M. Collins.

I am a physical therapy assistant. I was recently in a car accident. I have a small sports car and hit the left side of my head rather hard and had a bump approximately 4-by-5 inches, causing me to vomit, see dark spots, become sleepy, very dizzy/lightheaded and for the following four days, according to some of my friends (speech language pathologists), I appeared to have some aphasic symptoms. I have insurance through Kaiser Permanente and do not have a regular physician. The doctor I did see requested a CAT scan without contrast. The results were unremarkable. It has been nearly two weeks since the accident and I have found that I am doing odd things that are typical of brain-injury patients. I have left the oven on twice, I misname objects, have been unusually emotional and recently I was going to a movie with my fianci and I was wearing two different shoes and did not notice until we were in the parking lot at the movie theater and my fianci noticed I was limping and then looked down to notice my shoes were not a pair. I am right-handed, the shoe on my right foot was the one I wanted to wear and the one on the left was the wrong one. I am wondering if I have neglect on the left side, or perhaps I am just stressing and this is nothing. Please advise me if I should see another doctor or just relax. -- My head hurts

Put yourself in a theater. You become antsy -- suddenly you can feel every crease in your pants. Your collar is too tight. Your glasses don't fit properly. All of these sensations were present before you got antsy, but you didn't notice them. Your mind filtered out the irrelevant. But when anxiety takes away that filter, you become hyperaware of ordinary bodily sensations.

My first question would be: Are your symptoms neurological or do they stem from "hyperawareness," particularly in someone who is quite familiar with the expected symptoms of brain damage?

Post-concussion syndrome is a strange bird. On the one hand, each year hundreds of thousands of athletes experience true concussions (loss or alteration of consciousness with associated period of amnesia) yet have only transient symptoms that resolve within a couple of weeks. On the other, we have patients with minor head injuries who have complaints that linger for years.

Let's exclude those associated with litigation or other obvious ulterior motives. In the healthy individual who has smacked his/her head, it is often extremely difficult to determine whether the symptoms arise from a subtle brain injury or from mere worry that you might have a brain injury. The symptoms are similar, and invariably the standard tests -- neurological exam, MRI or CAT scan, or EEG -- are normal or reveal no definite specific pathology. Immediately you are up against the dilemma of psychological vs. neurological -- if I can be allowed such a simple-minded, Cartesian distinction. It is the old mind vs. body problem.

Of course, as the generator of the symptoms, you cannot tell, nor do you have appropriate wetware/software/programming (whatever you call the ability of the mind to diagnosis itself). You have the sensation but not the ability to categorize it. We must also keep in mind that the sensations of anxiety are as real as the symptoms of any brain lesion.

As patients, we notice what we are trained to notice. If we expect to be well in a couple of weeks (as athletes do), we tend to be well in a couple weeks. If we expect lingering symptoms, we are less likely to have a prompt recovery.

You have a choice. You can go to Internet support groups and read about the worst-case scenarios or you can draw upon your own common-sense experience. But the latter will be affected by your working with brain-injured patients. It is no wonder that "medical student syndrome" no longer occurs just with medical students.

As we went through med school, we developed a fair percentage of the diseases we studied. Amazingly, they tended to resolve on their own, only to be replaced by new conditions. (You would think that our experience would give us some degree of empathy, but human nature doesn't work that way. I think we doctors get embarrassed by all our imaginary infirmities and project our personal disappointments onto our patients. Perhaps this is also why so many seek junk science explanations for the clearly psychological.)

On a practical note: Consider your observation on possible neglect. (Neglect is a condition secondary to parietal lobe damage in which a patient becomes unaware of one side of his body -- usually the left side. He may actually ignore the left half of his visual field or fail to dress his left side.) You are not describing neglect, but its converse. You are not neglecting your left side; you are hyperaware of it, are drawing attention to it.

I cannot count the times that I have worn different shoes. But because I wasn't concerned about parietal lobe disease, I concluded that I was absent-minded, but not necessarily brain-damaged.

Try to listen to the syntax, the actual vocabulary of your complaints. They are a clue. You say, "I am doing odd things that are typical of brain-injury patients." You have jumped from observation to probable diagnosis. Try to learn how you are biased about your own complaints. They often give you a clue to the treatment.

In this case it is apparent that you believe your symptoms are synonymous with brain damage. If that belief persists, it is difficult to get rid of the associated anxiety that probably drives the symptoms.

You think: Well, maybe I should get another scan. But you already know that the chance of it being diagnostically abnormal is quite small. You want reassurance, which you recognize as being the best treatment.

A major stumbling block for a doctor is how to reassure without excessive testing, and without overwhelming the patient with literature that might help, or might actually aggravate the problem.

Ask yourself, "What would reassure me?" If all you need is a doctor saying that such symptoms seldom represent permanent damage from the injury you describe, then you have my reassurance (but not my guarantee).

Another sore point: In this world of litigation and accusation and finger pointing, no one in medicine wants to stick his neck out and give the final absolute word. We couch everything in generalities, none of which are reassuring to anyone but the doctor and his personal attorney.

You must learn to read between the lines. Trust your own common experience; realize that you are constantly bombarded with misinformation, medical salesmanship disguised as scare tactics and support groups beating their own drums of victimization. These are tough times to be a patient but, from what you describe, I think you will be just fine.

By Robert Burton

Robert Burton M.D. is the former chief of neurology at Mount Zion-UCSF Hospital and the author of "On Being Certain: Believing You Are Right Even When You're Not" and "A Skeptic's Guide to the Mind." A former columnist for Salon, he has also been published in the New York Times, Aeon and Nautilus, and currently writes a column at the Cambridge Quarterly for Healthcare Ethics.

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