Pulmonary and Non-Pulmonary Tuberculosis

By Miranda Goins & Bailey Gardner

Image from page 271 of "Tuberculosis : a treatise by American authors on its etiology, pathology, frequency, semeiology, diagnosis, prognosis, prevention, and treatment" (1909)
Image from page 271 of Arnold Klebs, Tuberculosis: a treatise by American authors on its etiology, pathology, frequency, semeiology, diagnosis, prognosis, prevention, and treatment (1909).

Tuberculosis, also known as consumption, is a mycobacterial infection that can infect many different organs in the human body (Brownell, 2013). The most common form of tuberculosis is pulmonary, however it can develop further into other body parts and become classified as non-pulmonary tuberculosis. In London in the early 20th century it was very hard to diagnose tuberculosis early, because it usually could not be detected until there were symptoms, and by the time there were symptoms it was no longer in the early stages and considerable damage had already been done (Croydon 1934). Different forms of tuberculosis have varying ranges of infectiousness, and due to the lack of detectable symptoms the many kinds of tuberculosis were wiping out a large portion of the population.

Lungs of a young man who died of Tuberculosis 1834. Credit: Wellcome Collection.

Pulmonary Tuberculosis

The most common form of TB is called pulmonary tuberculosis. An acid-fast bacillus, Mycobacterium, is its primary cause (Johnston, 1993). This could be a chronic disease that dragged out for months or even years, but it could also cause death in a matter of weeks or days.

Robert Brownell explains that pulmonary tuberculosis is typically spread by aerosol droplets. The sufferer coughs out droplets which are inhaled by someone who is in close contact. In 1939, the New York physician Jacob Segal, wrote a synopsis about pulmonary tuberculosis and went into great detail concerning the different ways TB can be dispersed. He explained that it could be conveyed by direct bodily contact such as sex and touching of the lips or hands. Some common modes of transmission of tuberculosis were: articles of public use (money, phones, books, doors), table utensils, towels or bedding, and even food. (Segal, 1939).  

Tuberculosis was also connected to nineteenth-century modern urbanity. Hristo Boev explains that tuberculosis could have been caused by drinking contaminated water or food products, breathing polluted air, and malnourishment of the poorest class. Those who were infected with tuberculosis were even advised to leave the city they lived in as soon as they could. Most importantly, he indicates that pulmonary tuberculosis was highly associated with metropolitan life in overcrowded areas (Boev, 2012).         

Interestingly enough, not everyone who is infected with tuberculosis becomes ill. For example, in Croyden in 1946, there were 35 active cases of tuberculosis. 18 individuals had symptoms of tb and 17 did not (Croydon 1946). However, for those who do experience symptoms, pulmonary tuberculosis typically begins with flu-like symptoms and gradually turns into a cough and then to more serious bodily malfunctions. Although it can begin with flu-like symptoms, the MOH of Battersea 1933 stressed that in most of their cases, patients almost always complained about their painful cough before anything else. MOH reports indicate that spitting of blood, haemoptysis, is an early sign of tuberculosis (Greenwich 1937). Furthermore, the MOH of the City of London 1938, explained that there was a reason to worry if there was extensive weight loss, more than one attack of the flu in three months, blood in the mouth, development of a cough, tiredness, or pleurisy.

Men were more likely to get pulmonary tuberculosis that women. Children were rarely affected. For example, at the end of 1929, statistics for Deptford showed that 370 men were infected with pulmonary tuberculosis and only 298 women (Deptford 1929).  This MOH report also shows the comparison of those who were infected under the age of 15 and above the age of 15. There was a huge gap between the ages showing that it was very rare for both boys and girls below the age of 15 to have pulmonary tuberculosis. Only 46 of the 370 males infected were under the age of 15, and only 39 of the 298 females. In 1930 the total number of cases of tuberculosis occurring in children were very slim. The Medical officer of Health report during that year shows that there were only four cases and all four were girls (East Ham 1930).    

The deaths and statistics of pulmonary tuberculosis have both increased and decreased overtime. There were 212 deaths in 1911 and 163 in 1912 where the majority of the deaths resulted greater in men than women. On the contrary, East Ham 1913 report shows that the notifications of pulmonary tuberculosis that year were fairly equal between men and women with 245 males and 247 women. In 1936, there were 1,238 cases of pulmonary tuberculosis with a death rate of 0.62 per 1,000 inhabitants (Lewisham 1936). Later in 1960, 200 notifications of tuberculosis were received with 182 of them being pulmonary. The attack rate per thousand during this time was 0.64 in contrast to 0.69 in 1959 and 0.73 in 1958 (Hackney 1960). One MOH report states that the smaller numbers could typically be due to transference to other causes (Paddington 1912). 

Non-Pulmonary Tuberculosis

Tuberculosis is capable of infecting many different organs. Although non-pulmonary tuberculosis occurs, it is not nearly as common as pulmonary tuberculosis. For example, in 1945 the death rate due to pulmonary tuberculosis and non-pulmonary tuberculosis per 1,000 people was 0.37 and 0.09 respectively. A year later in 1946 the death rate due to pulmonary tuberculosis and non-pulmonary tuberculosis per 1,000 people was 0.43 and 0.04 respectively (Croydon 1946).

Many times non-pulmonary tuberculosis is a direct result of pulmonary tuberculosis that has re-localized, but non-pulmonary tuberculosis can also arise on its own. The types of non-pulmonary tuberculosis are divided into 3 groups: cerebral cases, glandular cases, and bone and joint cases (Bermondsey 1920). Some common types of non-pulmonary tuberculosis that were recorded in the medical officer of health (MOH) reports include tuberculosis of the bones and joints especially large joints, the abdomen, peripheral glands, lymphatic glands, the spinal cord, and other organs (Croydon 1946 and Kensington 1913).

One rare type that was seen and has been studied is laryngeal tuberculosis, which in most cases is a direct result of pulmonary tuberculosis (Marfani and Beg, 1985). This type of tuberculosis greatly resembles laryngeal cancer and has been found to have either malignant or benign forms. The first form may stay inactive for a long time and eventually heal itself, or it may become active and infect other organs and tissues. The most common pathologies of this disease are lesions in the posterior part of the larynx. Laryngeal tuberculosis is one of the more infectious forms of tuberculosis.

Another form of tuberculosis that was seen was tuberculosis of the esophagus, which results in an obstructed esophagus due to swelling (Frew, 1950). A 51 year old male patient was examined by Dr. Richardson and was diagnosed with tuberculosis of the esophagus. He explained that there was a high probability that there was a tubercular lesion along with byssinosis that was potentially caused by his employment as an upholsterer for thirty plus years. (Frew, 1950).

In one of the MOH reports, Lambeth 1935, statistics of age, gender, and type of tuberculosis that caused death are recorded. Out of the 192 people who died from pulmonary tuberculosis 127 were males and 69 were females. Further, over 95% were above the age of 20. For non-pulmonary tuberculosis, 10 of 22 were males and 12 of 22 were females and only 36% were over the age of 20. In another MOH report, Kensington 1913, a little over 61% of the deaths attributed to pulmonary tuberculosis were people who were 25 years old or older. For non-pulmonary tuberculosis only 14% of the deaths were of people 25 years or older. Both these statistics show a trend in age differences between the two divisions of tuberculosis. Non-pulmonary doesn’t affect as many people as pulmonary, but it tends to affect a larger ratio of younger people below the age of 20-25 years old than does pulmonary tuberculosis. This is also seen in Deptford 1929. This report states that 69% of the people affected by non-pulmonary tuberculosis were under the age 15, while less than 13% of the people affected by pulmonary tuberculosis were under 15.

The chance of death after being infected with tuberculosis was very high in the 1900s. However, the chance of death from non-pulmonary tuberculosis was much lower than the chance of death from pulmonary tuberculosis. In Poplar 1937, the statistics from new cases show that a little over 57% of people who contracted pulmonary tuberculosis died as compared to about 30% of people who contracted non-pulmonary tuberculosis. The death rates per 1000 people for pulmonary tuberculosis and non-pulmonary tuberculosis were 0.79 and 0.08 respectively.

In Greenwich 1946, the medical officer reported a definite decrease in cases of non-pulmonary tuberculosis in recent years. He stated that although there was also a decrease in pulmonary cases due to a decrease in the population, the decrease in non-pulmonary cases was much larger and had to be due to other factors. He believes it must be at least partially due to the invention of pasteurization of milk, which is getting rid of many sources of infection. He does not explain why this affected the non-pulmonary cases but not the pulmonary cases, but it probably has something to do with how each type of tuberculosis is contracted.

As far as gender and the two division of tuberculosis go, there is a trend seen in many of the MOH reports showing that out of the total number of people who contracted non-pulmonary tuberculosis, a majority were female. The opposite is true for pulmonary tuberculosis, out of all the people who contracted pulmonary tuberculosis a majority were male. In Croydon 1966, out of the 1,700 people who contracted pulmonary tuberculosis 998 were males and 702 were females. In the same report out of the 1,846 people who contracted non-pulmonary tuberculosis, 85 were female and only 61 were male. This trend is also seen in Richmond upon Thames 1965, where 30 out of 56 people with pulmonary tuberculosis were males and 4 out of 5 people with non-pulmonary tuberculosis were females, and Greenwich 1952 where 430 out of 763 people with pulmonary tuberculosis were males and 26 out of 43 people with non-pulmonary tuberculosis were females.

Secondary Sources

Segal, Jacob. Pulmonary Tuberculosis: A Synopsis. Oxford University Press, 1939.

Johnston, William. 1993. “Tuberculosis.” Chapter. In The Cambridge World History of Human Disease, edited by Kenneth F. Kiple, 1059–68. Cambridge: Cambridge University Press.

Boev, Hristo. “Dickens’s Consumptive Urbanity: Consumption (Tuberculosis) through the Prism of Sensibility.” The Victorian Web , October 28, 2012.

Brownell, Robert, “The Dark Shadow: Consumption (tuberculosis) in the families of nineteenth-century writers,” in Marriage of inconvenience: Euphemia Chalmers Gray and John Ruskin: the secret history of the most notorious marital failure of the Victorian era. London: Pallas Athene, 2013.

Marfani, S. and M. H. A. Beg. “The Larynx in pulmonary tuberculosis.” The Journal of Laryngology and Otology 99 (1985): 201-203.

Frew, I. J. C. “Tuberculosis of the Esophagus” The Journal of Laryngology and Otology 65, no. 12 (1950): 774-775.