Protecting ourselves from tuberculosis. Describing a historic poster printed in italy on 1937.

Sir,

Pulmonary TB was the disease that spawned thoracic surgery and pulmonology. During the eighteenth and nineteenth centuries, the population shift to cities and the ensuing overcrowding contributed to TB being the most common cause of death. It was apparent that TB was a communicable disease but medical proof had to await Koch's presentation, entitled “On Tuberculosis” in 1882. Here at last was an enemy (the tubercle bacillus) to which attention could be directed.[1] Many folk remedy existed for treatment of the disease. One of the most popular myths was of a change in climate and diet. Ultraviolet light kills acid-fast bacilli in the laboratory, and therefore patients were encouraged to spend time exposed to sunlight. Physical activity in children supposedly conferred resistance. The first sanatorium specific for TB was established at Gobersdorf in Germany, another famous sanatorium was in Davos, Switzerland, the highest town in Europe but, between 1932 and 1940, in the Alps of Northern Italy, at 1000 m above sea level, the biggest sanatorium in Europe (Eugenio Morelli Hospital) was built in Sondalo with 9 wings for each of its 10 floors and covering an area of 350.000 m2 on a road network of 12.5 km and occupying a volume of 650.000 m3. “The Sanatorium City”, with its 3500 beds, cinema, shops and a post office, had a larger population than its nearby towns and was immortalized in a Vittorio De Sica film “A short holiday”. Sondalo is like Davos; two places that share the wonderful landscape of the Alps, the clearness arising from the intense green belt around, the daylight springing over the terraced meadows and the shining sunlight gathered as if in a bright amphitheatre.[1] The main activity of these structures was, from the beginning, the fight against the “insidious disease” called TB. High altitude, bed rest, exposure to the environment and good nutrition were pursued as therapeutic options. The Hospital soon became one of the first centers of reference in Italy and Europe for the treatment of TB and other lung diseases. In pre-antibiotic period, therapies against TB were ineffective and a major role was played by the surgery and largely by preventing the disease. Despite the hundreds of sanatoria built around the world, no tangible scientific proof that sanatorium therapy had any influence on the disease exists. Sanatorium therapy, however, concentrated patients in one place and so contributed to the study of the disease. The annals of Morelli Hospital are full of descriptions about surgical operations that were routine and today would just make us cringe. The techniques of thoraco-myoplasties, buckling and iatrogenic pneumothorax are just some examples of how and in what measure the surgeon could “demolish” a patient. The basic idea was valid, reducing the supply of oxygen to the tuberculous cavities to make survival difficult for the obligate aerobes organisms that are mycobacteria. Various methods of collapse therapy, like the “therapeutic pneumothorax of Forlanini” introduced in 1906 and the “intracavitary aspiration of Monaldi”, today are full of historic charm. The development of anti-mycobacterial therapy, in the second half of the last century, was a “godsend” for patients and a professional revolution for Thoracic Surgeon who had already understood the need to “sharpen the blades against cancer”, the new enemy whose incidence was increasing more and more! With the new medical therapy the role of the Surgeon gradually decreased to the treatment of complications of TB: Destroyed lobes and lungs, tuberculous pleural empyema with or without fistula, hemoptysis, etc., bronchoconstriction. Disease prevention was not easy in a period plagued by wars and dominated by poverty and lack of education. One of the sanitary objectives, that the political institutions of the period were trying to achieve, was the defeat of some of the most dangerous infectious diseases including TB. The poster in [Figure 1], printed in 1937 and currently exposed in the Phthisiology Department of Morelli Hospital in Sondalo, represents one of the most practical and fascinating historical examples of the attempt to focus social awareness on the problem of prevention. At the top left you can read: The messy house, neglected and untidy, away from the air and light, depresses the spirit and hatches germs of the saddest diseases; first and most insidious of all tuberculosis. At the top right you can read: The clean house, tidy, lovingly prepared and open to the pure air and to the beneficial sun, raises the spirit of those who live and keeps infections, contagions, the mortal dangers far away from the body. The text continues: Tuberculosis still kills every year 35,000 Italians. Yet, if it was discovered and treated in time, tuberculosis would have been the most preventable and most curable disease. Tuberculosis is caused by the bacillus discovered by Robert Koch, which, finding favorable conditions in the human body, grow, multiply and destroy organs and tissues. These bacilli that are found in the sputum expelled by coughing tuberculosis patients are really virulent and nefarious, especially when they act on children. When in a house there is a person sick with tuberculosis, we must take these precautions: Room aside, the destruction of the sputum, disinfection of table utensils. With all the forces it is necessary to fight the ridiculous fears that make a poor sick a being to be feared as a cholera victim, a pariah. But above all it is necessary to subtract the children to infection and strengthen their bodies. In fact, while the bacteria that infect a weak body have the fate of a lit match falling on a pile of straw, the bacilli entering a robust body have the fate of a lit match falling on a marble table: Extinguishes. To protect children from tuberculosis, you should: Wash your hands before touching any food; at school, sitting with chest and head erect, so that the apices of the lungs can breathe; to live as much as possible outdoors and do respiratory gymnastics; not spitting and prevent others from spitting on the ground; do not eat foods already touched by others; do at least one bath a week; sleep, when it is not raining and not too moist, with the windows slightly open so that fresh air can enter the room; eat healthy foods and brush your teeth before going to bed. By following these hygienic rules, you can almost always prevent tuberculosis. However, tuberculosis, at the beginning, is almost always curable if treated immediately and with appropriate methods. When the first symptoms, which include slight fever persistent and intermittent, which does not exceed 38 degrees; weight loss; pallor; lack of strength; fixed pain in the chest; coughing light, tough and dry; tenacious disorders of the stomach and intestine; streaks of blood in the sputum, seek immediate medical attention or anti-tuberculosis institutions created by the Fascist Regime, which has made the fight against tuberculosis among the fundamental objectives of its businesses. Let all remember the words of the Duce (tn: Benito Mussolini): “it is necessary that scientists, policymakers, philanthropists constitute a kind of united front to lead the great battle against tuberculosis to a victorious end.” Today a poster like that described could be perceived as biased because it seems to attribute responsibility for the spread of disease to poverty and therefore to a condition that cannot be changed or that can be changed with extreme difficulty. A closer reading, however, must reveal the merit of emphasizing, in a poor environment, only those aspects that can be changed at low cost. Nowadays, a number of challenges and barriers to good hygiene exist in less developed countries. The greatest of these challenges is the lack of clean water and soap. Hundreds of millions of people do not have access to improved sources of drinking water and worldwide there are 1.6 million deaths per year attributed to diseases spread through unsafe water, poor sanitation, and lack of hygiene.[2] The described poster, in that way can be considered current, because, even today, poor sanitations and many diseases are widespread among the lower classes but of course it is not a rule. In conclusion, in our daily activities we can confirm that the “new explosion” of TB, is due mainly to the migratory flows from highly endemic countries in our hospital (mainly countries from Eastern Europe and South Asia). Cases of resistant infections are also increasing. In addition to multi-drug resistant (MDR) and extensively drug-resistant (XDR) bacterial strains, we now must fight against infections that have very few chemotherapeutic options, a kin to the TB we saw in the pre-antibiotic era. The appearance of these resistant strains is due to a selection common to all germs and to an incorrect use of medical therapy (monotherapies, insufficient duration, poor patient compliance, etc). With the resurgence of the disease and the development of resistant strains and more complex patients, the Thoracic Surgeon must learn to deal with the “phoenix reborn” again.[3] The battle is increasingly complex and treatment of TB requires a close collaboration between the Physiologist and the Surgeon. Medical therapy of resistant forms must be handled by experts in the field and the corresponding surgical treatments cannot be improvised.

Figure 1

The poster showing the hygiene rules preventing tuberculosis