This article appears in the October 1947 edition of the Catholic Medical Quarterly

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TUBERCULOSIS AND FAMILY RELATIONSHIPS

By

C.M. Wilkinson, M.B., B.S., Medical Superintendent, Essex County Hospital, Black Notley, Essex.*

In Britain modern Catholics have fought a great battle for family life. In this paper, I am permitted to add my iota of in formation on this subject to the common fund of knowledge. This concerns the effect of tuberculosis on family relationships. During the past sixteen years I have been engaged in the treatment of all forms of tuberculosis and I have found that it is a disease which gravely attacks the foundations of family life, necessitating heart-breaking separations for long courses of treatment and other hardships. It is my purpose in this paper to examine the medical aspects of some of these conditions and to enquire how far some of the restrictions on tuberculous persons are justified by the facts of the case. It is scarcely too much to say that tuberculosis is the modern leprosy, and any hope and comfort that can be brought to sufferers from this disease are badly needed. Hope and comfort are also valuable additions to treatment.

I would like to start with the question of pregnancy and tuberculosis. At the Essex County Council Hospital, Black Notley, where there are three hundred Sanatorium beds for the treatment of tuberculosis, a maternity unit for tuberculous women was started in 1937, primarily due to the efforts of Dr. W. A. Bullough, M.Sc., the County Medical Officer of Health, Miss M. Ruck, R.R.C., the Matron, and the late Dr. W. Burton Wood, F.R.C.P. This work was started with some trepidation on account of the prevailing opinion in the medical profession about that time that pregnancy in tuberculous women was very often harmful. In spite of this attitude of the medical profession, however, many tuberculous women did become confined and provision for their confinement was a difficult problem as the majority of nursing homes and hospitals did not like admitting persons who might possibly be infectious. To meet this need the Maternity Unit at Black Notley was started, the first of its kind in this country. A similar unit had been in existence at the Sanatorium, Saranac Lake, in America, of which Jameson reported the work and the good results obtained in his book "Gynaecological and Obstetrical Tuberculosis" (Jameson 1935). I should, therefore, like to present for your consideration first the results of the work of the Unit at Black Notley.

These results have been compiled by my colleague, Dr. R. Chapman Cohen, who has been in charge of the Unit. He has recently published a full account of the work in the British Journal of Tuberculosis (Cohen 1945). Cohen starts his paper with a comprehensive review of the literature on this subject and remarks that it is surprising to find in view of present adverse medical opinion on this subject that the majority of articles on pregnancy and tuberculosis, and especially those articles in which evidence is quoted, are in favour of the view that pregnancy is not harmful to tuberculous women. He traces the trend of medical opinion from the time of Hippocrates and Galen who are supposed to have advocated pregnancy as a form of treatment for pulmonary tuberculosis. Until the middle of the nineteenth century, he says, it was believed that a phthisical woman’s health improved during gestation. About this time however, a complete reversal of opinion took place which some times went so far as to say that every pregnancy in a tuberculous woman, even though the disease was quiescent, should be terminated. Cohen thinks the pendulum has now swung to a more neutral position, but in any case there is no doubt of the need of a complete review of the facts of the matter by a physician of experience, such as Cohen, who has facilities for accurate assessment of the condition of the tuberculous patient.

Cohen published the results of 177 women admitted consecutively to the Maternity Unit. He first assessed the immediate results that is, up to the end of three months after labour. These immediate results are of major significance in a disease for which the mortality is in any case very high. If it is true that pregnancy is harmful to the tuberculous woman, that fact must appear clearly in the immediate results. Cohen divided the patients into three sub-divisions, those with arrested disease, those with quiescent disease, and those with active disease. Any patient with any clinical or radiographic evidence what ever of re-activation was included in the group of patients who had retrogressed. The figures for immediate results (within three months of labour) are summarised thus:

Type of Disease

Number of patients

Number retrogressed
Arrested or recovered

69

3
Quiescent

50

5
Active

58

15

Total

177

23

Cohen’s later results were estimated on follow-up records of patients at periods varying from six months to six years after confinement. Records were obtained of 12() cases. Results may be summarised as follows :

Type of Disease

Number of patients

Number of Deaths

Number regressing
Recovered

53

2

2
Quiescent

35

-

1
Active

32

10

5

Total

120

12

8

It will be noted that 120 out of 177 patients were followed up. This follow-up period covered the war years when there was a dispersion of population from the extra-metropolitan part of Essex and this is a sufficient reason to account for its incompleteness.

Cohen's results must next be considered in comparison with a control series. To find accurate controls is almost impossible in tuberculosis research. But Brian Thompson, Tuberculosis Officer of the Middlesex County Council, has recently published the mortality rates found as a result of a follow-up of more than 400 patients suffering from pulmonary tuberculosis, who had active disease with cavitation. (Thompson, B.C. 1943.) These were patients in whom there is no mention of any pregnancy. It is permissible to compare the patients in Thompson s series with the patients in Cohen s series, classified as patients with active disease. Thompson found that "the early case fatality was particularly striking in his series, 42 per cent, of the patients dying within twelve months from the time of diagnosis; at the end of the first five years 75 per cent. of the original total were dead; of the survivors one half died within the second five years." In other words, of any eight patients with positive sputa only two would be expected to survive five years and one to survive ten years.

The following points thus emerge. In Thompson s series the mortality rate of patients was an early case fatality of 42 per cent, within twelve months from the time of diagnosis: at the end of the first five years 75 per cent. of the original total were dead. In Cohen’s cases with pregnancy in which the follow-up ranged from six months to six years after discharge from the hospital, the mortality was 33 per cent. Secondly, the mortality rate and the incidence of retrogression in Cohen’s cases was so small as to be without significance in a disease in which the prognosis is so uncertain. The figures quoted by Cohen are certainly re assuring for all three groups of his cases.

Several further comments can be made. In Cohen's im mediate follow-up results of 58 patients with active disease fifteen are shown as developing any evidence of retrogression. Cohen points out that ten of these patients were suffering from advanced bilateral disease in whom the prognosis would in any case have been almost certainly hopeless. He also points out that 32 of the 58 cases with active disease showed improvement after labour and 12 were quiescent by the time they were dis charged. A last comment and a word of caution is that Cohen s figures relate to patients confined under Sanatorium conditions and with the amenities for treatment in a modern tuberculosis hospital at their disposal.

In my opinion Cohen's figures justify the conclusion that Black Notley patients as a group did not suffer from having their tuberculosis complicated by a pregnancy. When compared to Thompson s patients it may even be considered that as a group they benefited. I will consider later whether any scientific explanation can be offered of increased resistance to tuberculosis due to pregnancy. But I will now go on to state that a further series of controls is necessary; namely, the results of a series of patients treated by abortion. But I have not so far in the literature been able to find the record of any such series. Such a series of results would be most interesting. They would also, in my opinion, be most illuminating. The dangers attendant on this procedure were stressed at a meeting of the Tuberculosis Association in November, 1945. I have also heard similar opinions expressed by gynaecologists in private conversation. There is no evidence of which I am aware available to support the theory that artificial abortion is a therapeutic measure for the tuberculous patient.

Before leaving the results of the work of the Black Notley Maternity Unit two other of Cohen’s observations are worthy of a brief mention. First, that multiparity was not a factor conducive to retrogression; multiparous women belong to a later age group more resistant to tuberculosis; secondly, that the length of time which elapses between the quiescence of the disease and the first pregnancy was also not significant.

I can now turn for a few minutes to the social and economic side of the question. It is often said as an argument in favour of abortion that even if a tuberculous woman can be safely confined the strain of looking after even a small family would be detrimental to her. This is an argument which appears to be based upon speculation only. Surely the "joyous mother of children" is no less healthy a person than her less fortunate sister without children. It is necessary to consider the circumstances of many of these patients. Phthisis is a disease which strikes hardest at the young female following the age of adolescence. For many of the young women treated at Black Notley, the future held only these alternatives, either to eke out a meagre existence from wages earned in a factory, to marry, or to be come the unwilling burden on a family in a suburban villa, in some cases no doubt already overcrowded. The natural inclination of many of the girls is undoubtedly towards marriage. What are the prospects for them if they do marry? Is marriage necessarily disastrous? One answer to this question has been given by Lyman in America (Lyman 1943). Lyman followed up 1818 women treated for tuberculosis in a Sanatorium. A large group of these married after leaving the Sanatorium in spite of medical advice to the contrary. Lyman found that the late results of treatment were four times as good in the patients who married as in those who remained single. Lyman says "When we consider that this 'later married group established this record in spite of the fact that 192 out of 315 gave histories of pregnancies (averaging 2.25 children each), it is clear that some factor not yet accounted for has exerted a profound influence in their cases."

What this factor may be I will venture to speculate about later. It might be argued that no special factor to increase resistence to tuberculosis existed in Lyman’s cases, but that the better results in the married group were due to their being a favoured group who were fitter and had recovered better than the others. But support for the special factor increasing resistance to tuberculosis in the married person can be found from another observation, which is accepted by the majority of phthisiologists, namely, marital contacts are a relatively immune group of contacts. I have been able to confirm this observation from records at Black Notley.

If then it is conceded that neither pregnancy nor marriage is necessarily unfavourable to the tuberculous woman, the final criticism must be answered that the child born of the tuberculous mother is a child born to a grievous heritage. There is still a prevailing opinion among medical men as well as laymen that although the tubercle bacilli themselves are not inherited, yet the tuberculous diathesis or constitutional pre-disposition to tuberculosis is passed on from generation to generation and that the child of a tuberculous parent would very likely succumb to the disease sooner or later.

Before discussing this it should be remembered that resistance to tuberculosis varies considerably with the age and sex of the patient. Among infants of under a year or eighteen months there is a high susceptibility to tuberculosis, and if the infant becomes infected the results are very often fatal. During child hood the resistance to tuberculosis becomes comparatively high. Following adolescence in the female there is a period of increased susceptibility, and the disease is very fatal in young women. In the male, resistance to tuberculosis diminishes temporarily about middle age.

First it is necessary to consider the effect of tuberculous infection of infants and to assess how grave the danger is. There has recently been much correspondence in the British Medical Journal about this subject following Professor Moncrieff’s Varrier Jones Lecture, in which he put forward a plea that paediatricians should play a greater part in the scheme of tuberculosis authorities in preventing and treating tuberculosis in infants. Professor Moncrieff’s views seem to imply that tuberculosis specialists viewed this aspect of their work with too much complacency. Various tuberculosis specialists replied, mainly that the incidence of fatal tuberculosis in infants was so small that it formed one of the least of their problems. Roodhouse Gloyne in his excellent book "Social Aspects of Tuberculosis" quotes Calmette as saying that in France in tuberculous house holds the mortality from the disease in infants up to the age of a year was over 24 per cent. Calmette was using this as an argument in favour of the use of B.C.G. and no one has more sympathy with this advocacy of Calmette’s for B.C.G. than myself. Gloyne gives English statistics for households containing a sputum positive person as from 1.7 per cent. to 3.2 per cent. mortality of infants up to a year. At Black Notley, Cohen followed up 68 infants born of tuberculous mothers in the Unit at Black Notley; two had died of tuberculosis. Eleven of these mothers were sputum positive and the two children who died both had a sputum positive mother. Even from these figures there is a very good chance of the survival during infancy of a child born to a tuberculous mother. Confirmation of the theory that even infants possess a fair degree of resistance to tuberculosis comes from the experience of the Lubeck disaster. In 1930 at Lubeck 251 infants were given by the mouth during the first ten days of life three doses of B.C.G. Vaccine to which a virulent strain of tubercle bacilli had gained access by accident. As a result 77 infants died. To my mind it is very striking that 174 of the infants should have withstood these heavy doses of tubercle bacilli. A follow up of these survivors showed them in good health in later years; massive calcifications had occurred in the glands of the body but the evidence was that they had completely resisted the infection.

It seems, therefore, that even in the most susceptible age group the chances of the survival of the infants of the sputum positive mothers are much greater than the chances of succumbing to the disease. B.C.G. has not up to the present been used in Britain but there is now a strong feeling among British tuberculosis specialists that an extended trial must be made of it, or of some similar vaccine. Quite apart from the use of this vaccine, much may be done to safeguard the health of the infant by careful education of the mother in these matters.

Granted that a large majority of these infants will survive, what of their future? Toussaint and Pritchard (Toussaint and Pritchard, 1944) have recently published illuminating work on this question. They compared the mortality rates from tuberculosis of various groups of persons in the community. They found that there was a noteworthy mortality rate among infants born to tuberculous parents but that if they survived infancy this group showed a negligible incidence of tuberculosis in later life. Another group of persons born of healthy parents showed a higher mortality rate from tuberculosis when adult years were reached. This mortality rate was ascribed to the impact of tuberculous infection on persons who had never previously been in contact with the disease.

Relevant to the results of infection in childhood is some work done at Black Notley by Cureton and myself (Wilkinson, M. C. and Cureton, R. J. 1944). Case histories of more than a thousand women admitted consecutively for the treatment of pulmonary tuberculosis were examined. It was found that patients who were likely to have had contact with the disease during childhood formed a minority, 216 out of 1038 patients. In this smaller group it was found also that the disease seemed to be more sluggish and the patients in this group had a better resistance than those in the larger group who had no history indicating childhood contact with the disease. This theory is in accord with the teaching of the French paediatrician, Marfan, (Marfan, A. B. 1931) who taught that children who develop tuberculosis of the lymph glands and who recover, as they do almost invariably, develop a permanent immunity to the disease. My own experience certainly leads me to agree with Marfan. More than 1,000 children have been treated in our children s wards at Black Notley during the past sixteen years. Some of them have long passed the age of adolescence, when the risk of developing phthisis might be great. Yet only exceptional cases have come back to us on account of the development of phthisis.

The basis of resistance to tuberculosis in childhood lies in the fact, pointed out by Le Gros Clark (Clark, W. E. Le Gros 1939) and others, that during childhood the reticulo-endothelial and lymphatic tissues reach their peak of development. Calmette (Calmette, A. 1923) showed that the lymph glands formed a barrier against the invasion of the blood stream by the tubercle bacillus. The reticulo-endothelial cells and the lymphocytes are particularly concerned in antibody formation. Further evidence in support of Marfan’s theory was obtained by the examination of the records of more than 1,000 women suffering from pulmonary tuberculosis, already referred to. Only 3.2 per cent, of these cases showed in the X-rays of their lungs definite and marked calcifications at the lung roots indicative of previous tuberculosis in the glands in this locality. Osler also published a series of 2,000 patients dying of pulmonary tuberculosis of whom on autopsy 3.2 per cent. were found to have old calcified tuberculous glands. Phthisis therefore is not a usual sequel of glandular tuberculosis.

Therefore, the child of the tuberculous parent will be in some danger during infancy, but this danger becomes considerably less during childhood, and the primary infection that occurs as a re sult of contact with the parent is likely to produce a lasting im munity. This does not mean to say that a child can be exposed with impunity to tuberculous infection. The resistance may be lowered temporarily by trauma or infectious disease such as measles, and skeletal tuberculosis or miliary tuberculosis may supervene. Nor does our knowledge of tuberculosis in the child make it prohibitive for the tuberculous mother to rear the child successfully if she takes the proper precautions.

Up to the present I have tried to keep to the straight and nar row path of recorded observations and facts, but before finishing I venture a few observations of a more speculative nature.

I have earlier suggested that both marriage and pregnancy may raise resistance to tuberculosis. A study of the sex hormones may afford a clue to this matter. The hormone produced by the corpus luteum in pregnancy is a sterol: possibly in the married state there is greater production owing to sexual activity of the sex hormones, testosterone in the male and oestrin in the female, which are sterols. Green Armytage (Green Armytage,Y. B. 1942), has recently reported that as a result of invest igations carried out at the West London Hospital it was thought that the full development of the female genitalia following marriage is due to the absorption of hormones, such as testoserone by the vagina from the human semen. During pregnancy there is a rise in the cholesterol content of the blood. Thus it would seem that in the married state and in preganncy there is a higher sterol content in the body. Vitamin D, which is a sterol, has long been used for the treatment of tuberculosis; dermatologists have recently reported success in the treatment of lupus with calciferol, another sterol. Cruickshank (Cruickshank, D. B. 1942) has pointed out that there is an inverse relationship between tuberculosis and carcinoma. This might be accounted for on the basis of the increase in resistance to tuberculosis due to sterol formation, and the increased tendency to carcinogenesis due to sterols as many carcinogenic agents are sterols.

Experimental evidence of the effect of increased sterol forma tion in resistance to tuberculosis is still scanty. Steinback and Klein (Steinbeck, M. M. and Klein, S. J. 1937) have published experiments from which they claim that administrat ion of gonedotropic hormones to animals retarded the progress of tuberculous disease in those animals. Gonedotropic hormones are alcohols but they promote the formation of oestrin and progesterone which are sterols. There have also been published recent experiments by French workers (N�gre L. et al, 1945), who claim that guinea pigs fed on a diet rich in fatty acids were more resistant to tuberculous infection than a control group on a normal diet. On the other hand a group of workers in America (Aycock, W. L. and Foley, C. E. 1945), have published experiments from which they deduced that animals into whom sterols had been injected had a diminished resistance to tuberculosis.

From what has been said in this paper it must not be under stood that marriage and child-bearing are to be advised in the tuberculous woman. Tuberculosis is a fell disease and a woman with tuberculosis who marries undertakes a serious responsibility. But this article is intended to present the case for the tuberculous woman, and for her children. It appears to me that it is a case not sufficiently realised either by the medical profession or the lay public.

To the Catholic wife and mother who has tuberculosis it may bring a degree of reassurance and to many others also.

If we can extend a ray of hope to those hard pressed people, it is not only a humane duty but good treatment.

Dr M. C. Wilkinson has been elected a Hunterian Professor of the Royal College of Surgeons for 1948. Ed.

BIBLIOGRAPHY.

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