TUBERCULOSIS

The symptoms of tuberculosis, more often called consumption or phthisis in the nineteenth century, have been known in Europe for many hundreds of years. A Dublin physician described consumption of the lungs in 1772 in much the same way as modern medical treatises do—as an obstinate cough, inclination to vomit, oppression of the chest, habitual fever that increases after eating, general paleness, high pulse, night sweats, loss of weight, and coughing up of blood. Infection with the tubercle bacillus was widespread in Europe; some calculations for the early twentieth century suggest an almost 100 percent rate of infection. But though not all who were infected went on to develop the full-blown disease, mortality was high. At the height of the epidemic possibly at least two-thirds to three-quarters of those who had the disease died, most commonly from respiratory failure. Even among the recovered, tuberculosis could return in later life.

Some historians see the high rates of tuberculosis in Europe in the eighteenth and nineteenth centuries as the downward curve of an epidemic that had reached its peak several hundred years before. Others argue that a deteriorating urban environment caused an increased incidence in the early nineteenth century. All agree that in most European countries—Ireland and Norway were the exception—tuberculosis was on the decline in the late nineteenth century. Nonetheless, of all the infectious diseases, tuberculosis was the most important contributor to mortality in the nineteenth century and, while its decline continued into the twentieth, it was still the leading cause of death among young adults. Tuberculosis was more prevalent in the cities and towns. There is some evidence that in the nineteenth century, with important exceptions, mortality from tuberculosis was higher among women than men in rural areas, whereas the reverse was true for the towns; no definitive explanation for this variation is known in the early twenty-first century.

modern concepts of tuberculosis

Modern concepts of the causes of tuberculosis date from 1882, when the German scientist Robert Koch identified the bacteria responsible for the disease. Before then only two significant developments had taken place that affected the understanding of tuberculosis. One was the refinement around 1816 by the French scientist René-Théophile-Hyacinthe Laennec of the stethoscope, which aided better diagnosis; the other was the microscope, which enabled the identification of the characteristic lesions or "tubercles" that were present in the infected organs of sufferers. This established that, although consumption of the lungs was the most prevalent form of the disease, it could be found in other parts of the human body. It also gave the disease its modern name—tuberculosis.

Before Koch it was not known whether tuberculosis was infectious, though some doctors suspected it was. It was widely believed to be hereditary, and this led to families concealing the disease. Innumerable cures were offered in the early nineteenth century, all in retrospect valueless, including inhalation of iodine, a diet rich in fat, water cures, and even starvation. Some doctors attributed its incidence to overindulgence. By the middle of the nineteenth century, climate was considered to be an important influence on tuberculosis, and medical journals of the period are full of investigations of the incidence of tuberculosis in different climates around the world. This led sufferers to take tours or voyages in search of a climate they hoped would improve their health. A significant number of immigrants from Europe to the New World and the colonies were tuberculosis sufferers.

The lingering nature of death from consumption of the lungs and the fact that it seemed to strike the young in their prime led to a romantic iconography growing up around the disease in the nineteenth century. Some symptoms—flushed cheeks, glittering eyes—were considered to enhance beauty. The febrile excitement that sufferers often displayed in their psychological reaction to their illness led to an association between susceptibility to tuberculosis and emotional and artistic temperaments. Thus in operas, novels, and art, death from tuberculosis was used as the climax of a tragic

narrative of unfulfilled promise and youthful hopes dashed. Most famously the theme appears in the death of Mimi in Giacomo Puccini's opera La Bohème (1896), based on Henri Murger's novel of 1849. However, there are many examples in real life of the impact of tuberculosis on promise. The disease claimed the composer Frédéric Chopin at thirty-nine; the Brontë sisters Emily, Anne, and Charlotte at ages thirty, twenty-nine, and thirty-eight respectively; and the playwright Anton Chekhov at forty-four and the poet John Keats at age twenty-five.

treatment

The belief that fresh, uncontaminated air was good for the tuberculosis sufferer gained ground in the nineteenth century and came to dominate treatment of the disease. One product of this was the specialized tuberculosis hospital or sanatorium situated in an area chosen for climate and fresh air. The most famous example was the hospital in the German Black Forest opened by Dr. Otto Walther in 1888, which combined bed rest, medical attendance, and exposure to the air. Sanatoriums based on similar principles, catering initially to the private patient, opened throughout Europe. Isolated mountain retreats in Europe, brought within reach by the railway, experienced burgeoning local economies built on the provision of sanatoriums for the tubercular. The sanatorium led to the development of a specialized form of hospital architecture and to a literature based on the patient's experience. Every European country produced novels of sanatorium life, most now forgotten. However, the most famous is the German novelist Thomas Mann's The Magic Mountain, published in 1924. This was the year that the writer Franz Kafka, whose life and work was also over-shadowed by the disease, died from tuberculosis in an Austrian sanatorium.

The late nineteenth century saw a dramatic change in attitudes toward tuberculosis. Koch's discovery of the infectious nature of tuberculosis opened up the possibility that it could be susceptible to the kind of public health measures that had once been used to combat the "fevers"—the epidemic diseases such as cholera, typhus, and smallpox. These included notification, isolation, and decontamination. Between 1890 and 1914 nongovernmental organizations emerged in Europe, usually initiated and led by medical professionals. They raised consciousness of the disease among the public, advocated hygiene, and strove to bring the benefits of the sanatorium within reach of the poor. The principle they operated under was that the disease could be prevented, contained, and perhaps even cured. Thus tuberculosis became a focus for private charitable and eventually government action. A series of international conferences acted as a vector for the spread of ideas about its treatment across Europe. They encouraged comparisons between national tuberculosis rates, though the figures these comparisons were based on were notoriously unreliable. Nonetheless, this helped to make lowering the national tuberculosis rate a matter of patriotic duty.

There were national styles in the public health treatment of tuberculosis. Germany was the country with strongest adherence to the sanatorium; France to the outpatient clinic dealing exclusively with tuberculosis—the tuberculosis dispensary. Some countries had a system of compulsory notification of sufferers, others resisted. Two significant disparities in tuberculosis policy concerned the use of the antituberculosis vaccine BCG and the treatment of bovine tuberculosis. Koch's discoveries had encouraged the search for a vaccine against tuberculosis and in 1921 two French scientists Albert-Léon-Charles Calmette and Camille Guérin announced the discovery of BCG. By the 1930s it was in use in France and Scandinavian countries but elsewhere, particularly in Britain, its value as a preventative measure was questioned. By the 1940s, however, the use of BCG, particularly for children, had become widespread in Europe.

The second was treatment of bovine tuberculosis. Tubercles similar to those seen in humans were observed in animals, and the bacteria Koch found in affected humans was also present in animals. But he doubted, incorrectly, that tuberculosis could be transmitted between animals and humans. In the first decade of the twentieth century experimental proof that it could be so transmitted was available and generally accepted. The chief vector was in the milk and meat of infected animals, primarily cattle. Tuberculosis transmitted by milk affected the bones and internal organs of children in particular. This led to another familiar figure of the nineteenth century—the severely crippled child. Improved agricultural practices and pasteurization of milk eventually led to decline in tuberculosis of bovine origin, but the politics of agriculture intervened in some countries to slow down reform.

See alsoDisease; Public Health.

bibliography

Barnes, David. The Making of a Social Disease: Tuberculosis in Nineteenth-Century France. Berkeley, Calif., 1995.

Bryder, Lynda. Below the Magic Mountain: A Social History of Tuberculosis in Twentieth-Century Britain. Oxford, U.K., 1988.

Dormandy, Thomas. "The White Death": A History of Tuberculosis. London, 1999.

Jones, Greta. "Captain of All These Men of Death": The History of Tuberculosis in Nineteenth and Twentieth Century Ireland. New York and Amsterdam, 2001.

Smith, Francis Barrymore. The Retreat of Tuberculosis, 1850–1960. London, 1988.

Greta Jones