Tuberculosis and the acquired immune deficiency syndrome.

A review of tuberculosis and the acquired immune deficiency syndrome (AIDS) would be incomplete without reference to the history of both conditions. Tuberculosis was known in antiquity; characteristic lesions of spinal tuberculosis have been described in the skeleton of a neolithic man and acid-fast bacilli have been seen in pre-Columbian Peruvian mummies with lesions compatible with tuberculosis (Clark et al. 1987). The aetiological agent, however, remained in doubt until the late 19th century when Villemin’s earlier work supporting the theory of infection was confirmed by Koch’s discovery of the tubercle bacillus in 1882. This gave impetus to the search for an effective remedy for the disease as, for centuries, treatment had been merely palliative (Keers 1978). Hippocrates (460-355 BC) had advocated rest, baths, attention to the bowels and a liquid diet in the acute phase, and mild exercise, a diet of rich, easily digested food with milk taken liberally, for the chronic case. Drugs, which were mainly purgatives and expectorants, were used sparingly. Galen’s (13 1 AD) treatment consisted of rest, restraint of cough and a ban on visitors to eliminate the strain of conversation. Good food was considered important and fresh milk was a specific in pulmonary ulceration. Patients suffering from scrofula, a term applied to tuberculosis of the neck glands, could, from the time of Clovis the Frank (496 AD), attend the ceremony of touching for ‘The King’s Evil’ which was based on the belief in the royal power to heal (Crawfurd 1911). In England the practice began with Edward the Confessor and who was encouraged to practise the art to demonstrate the divine right of the Stuarts. The ceremony was conducted for the last time in England on 27 April 1714, three months before her death. By the time of Koch’s discovery, the sanatorium regimen had already been conceived, but greater energy was directed both to general measures, with emphasis on fresh air, good food, rest for the body and mind and, specifically, to rest for the diseased lung in the form of collapse therapy. This had first been introduced by the physician John Carson who, in 1881, presented a paper on ‘Lesions of the Lung’ in which he described his experimental work on induced artificial pneumothorax in rabbits which had subsequently recovered. The work had been based on his belief that the elasticity of the lung, which kept it permanently stretched, was the cause of the difficulty observed in the healing of parenchymal lesions. The difficulty could be overcome by reducing the lung to a state of collapse. For those patients in whom pneumothorax was indicated but technically impossible owing to adhesions, the problem was solved by the introduction of adhesion section thoracoscopy and cauterization, a technique devised in 1913 by Hans Christian Jacobaeus of Stockholm who had invented the thoracoscope. Other techniques of collapse therapy followed over the succeeding years including pneumoperitoneum, phrenic paralysis and thoracoplasty, leading up to the 1940s when lung resection was introduced. Initially, morbidity and mortality was high but after the introduction of effective anti-tuberculosis drugs, the operative risks were