Plagues in World History (19 page)

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90 y Chapter 3

But it was not until the modern era that tuberculosis apparently reached epidemic proportions in Europe. At the end of the Middle Ages, in the late fifteenth century, tuberculosis was already the leading cause of death among the monks of Christ Church Priory in Canterbury, England, accounting for almost a third of all cases of disease diagnosed in the community.3 By the seventeenth century, hospital and other records indicate that “consumption,” as the disease became known at this time, caused a fifth of all deaths in Britain, and perhaps as much as a quarter of Europe’s population was infected by the disease.4 It should be no wonder, then, that the English author John Bunyan should famously call consumption the “captain of all these men of death” in his fictional biography
The Life and Death of Mr. Badman
published in 1680. By the next century, consumption was thought to be causing fully a third of all deaths in Europe, and mortality and morbidity from the disease probably peaked at the end of the eighteenth and during the first half of the nineteenth centuries, before beginning a long, slow decline from the 1860s on the Continent and from the 1870s in Britain.5

The bacillus responsible for tuberculosis was not discovered until 1882 by the German physician Robert Koch (who in the next year also uncovered the Vibrio bacterium that causes cholera). Koch’s claim to have found a cure for tuberculosis, a solution containing kil ed bacteria that he cal ed “tuberculin”

and which he unveiled in 1890, proved to be premature, but it did form the basis for a skin test of the disease that is used to this day for diagnostic purposes.6 (Only those who have been infected will develop an allergic reaction to tuberculin.) A true cure for TB had to wait until 1943, when the first of the antibiotic drugs effective against the disease, streptomycin, was discovered by a Rutgers University biochemistry professor, Selman Waksman, and his laboratory assistants, Albert Schatz and Elizabeth Bugie.7 This was later followed by other drugs that are now frequently used in conjunction with streptomycin to treat tuberculosis, including para-aminosalycilic acid (PAS), isoniazid, and rifampin. In the meantime, a vaccine for tuberculosis was developed by two Frenchmen who headed up the Pasteur Institute at Lille, Albert Calmette and Camil e Guérin, who first tested their formula containing an attenuated form of the tuberculosis bacillus, known as
bacille
Calmette-Guérin (BCG), in 1921.

Even now, however, after nearly a century of trials, there is considerable debate among medical experts as to whether BCG does, in fact, provide any effective immunity; some contend it actually does more harm than good by making it difficult to diagnose whether a patient has active or latent TB.8 It did not help that, early in BCG’s history, a batch contaminated with live tuberculosis bacteria was mistakenly given to 249 babies in Lübeck, Germany, in 1930, with disastrous consequences. Tragic accidents like this one continue to be the bane of modern vaccination programs down into quite recent times, such as the asso-Tuberculosis y 91

ciation of a 1976 swine flu vaccine in the United States with a rare paralytic disease, Guillain-Barré syndrome (see chapter 5).

Yet, the steady decline of TB for almost a century prior to 1943 does pose something of a mystery. How could this happen in the absence of antibiotics?

Before 1882, doctors did not even have a clear understanding of the real causes behind tuberculosis. Contagion was accepted by some, just as it had been with respect to plague since the Middle Ages, but this had to compete with other explanations, including heredity; social/moral behaviors that could predispose a person to the disease, such as alcoholism or promiscuous sexual intercourse (resulting in syphilis); and a host of environmental factors, including poor hygiene, stress, overcrowding, and poverty.9 Even after Koch’s earth-shattering discovery of
Mycobacterium tuberculosis
, debate continued as to just how the microorganism was communicated person to person; we in fact know that environmental factors such as overcrowding do make one more susceptible to tuberculosis, as the disease is rampant today in prison populations, particularly in Russia, where prisoners must sleep in shifts since there are as many as three inmates for each bed in a cell.10 Belle Époque Frenchmen were quite right to campaign against spitting as a hygienic measure against tuberculosis, as we now know that the bacterium, in its dried form, can more easily penetrate to alveolar sacs deep inside the lungs carried on dust particles stirred up in the air rather than in larger liquid droplets emitted by contacts, and poverty naturally makes such conditions more likely.11 We also know from recent experience that TB can behave like an opportunistic infection glomming on to other diseases, particularly AIDS, that are largely based in social and moral behaviors.12 Finally, since it is as yet imperfectly understood why only one in ten people who are infected with the bacterium actually develop full-blown TB, while in the rest of the population the invading organisms are “walled off” in the lung in caseous or fibrous nodes known as “tubercules,” there still seems to be a role to play by individual predispositions, such as heredity.13

Even by the standards of what was known at the time, preantibiotic treatment of TB was woefully ineffective. Bleeding was a standard medical response right up until the mid-nineteenth century; it is sometimes claimed that a phlebotomy could alleviate the symptom of haemoptysis, or the coughing up of blood from the lungs, which was taken as a sure sign of tuberculosis (made famous by the self-diagnosis of the English poet John Keats, who called the blood on his pillow “my death war-rant”). However, I know from my own personal experience with this symptom (the result of chronic bronchiectasis, not tuberculosis) that only antibiotics can truly alleviate it, as the seeping of blood into the lungs will persist so long as bacterial infection remains and inhibits the healing of any scarring into the blood vessels surrounding the alveolar sacs. But starting in the second half of the nineteenth 92 y Chapter 3

century, the sanatorium movement began to take over as the preferred method of treating the tubercular, first in Germany and then in Switzerland, where the resort at Davos became the most famous, visited by international luminaries, and that served as the setting for the novel by Thomas Mann,
The Magic Mountain
. By the end of the century, these were joined by the “cottage system” of Saranac Lake in the Adirondacks in upstate New York, founded by a physician who was himself suffering from the disease, Edward Livingston Trudeau.

The early sanitoria operated on the principle that a supervised regimen of rest and mild exercise in the bracing mountain air, supplemented by a nourishing, if not gluttonous, diet of at least three full meals a day would give the body an opportunity to exert its own natural healing powers and effect a cure of tuberculosis. The principle was not a new one, as it could be found going back to at least ancient times, and the idea of retreating to a special climate for tuberculosis was the fashion among consumptives in the earlier part of the century who favored the warmer climes of Italy, southern France, or Spain. Trudeau’s famous experiment with rabbits notwithstanding, it is not clear that the sanitoria did much beyond confirm the natural progression of the disease in the patient; not even the much vaunted benefit of isolating patients from the general population is as clear cut as it might seem. Patients were usually released after a six-month period, when they were still very much infectious, and only a small minority ever had the privilege of visiting the sanatoria in the first place, as these were usually limited to early, “curable” cases of the disease or to those who could afford to pay, although some charitable institutions were set up in Britain and the United States, which survived on donations or the free labor of their inmates.14

The last phase of tuberculosis treatment before the advent of antibiotics was perhaps the most brutal and was not any more demonstratively effective: this was the “collapse therapy” of performing an artificial pneumothorax on the patient by inserting a hollow needle into the pleural cavity of the chest and introducing a measured amount of air in order to collapse the lung. (Sometimes injections of paraffin wax or oil were substituted for air to try to make the collapse more permanent.) Although the procedure was first introduced during the nineteenth century, it reached the height of its popularity during the 1920s and 1930s and was based on the same theoretical principles as the sanatoria (where most pneumothorax operations took place): that the lung would benefit from a resting period when it would allow itself to heal. Although a collapsed lung would, in theory, deprive the bacteria of oxygen needed for growth, this was a dangerous procedure prone to complications, such as a gas embolism in the circulatory system when the needle was not inserted correctly, which could result in death.

It was also not painless, especially after the effects of local anesthetic wore off, when patients commonly described the feeling of having a “mule kick” or a Tuberculosis y 93

“knifelike pain” delivered to their chest, and it was a procedure that had to be repeated with “refills” of air injection on a regular basis if the lung was to remain collapsed for long periods. In frequent cases where the lung adhered to the pleura due to the normal fibrous scarring of tuberculosis, open chest surgery had to be performed, with even greater risks of fatal side effects. At its most extreme, this surgery entailed removing part of the rib cage entirely, a procedure known as thoracoplasty, and cutting or removing the phrenic nerve, which paralyzed the diaphragm, in order to achieve permanent collapse, but patients ran a high risk of severe blood loss and shock. Overall, what follow-up studies were done of pneumothorax and thoracoplasty surgery showed that 50 percent or less of patients were still alive a few years later to justify such radical intervention; in a large minority of cases, it was estimated that it was completely unnecessary to the patients’ chances of recovery.15

Given these dismal results, it still remains to be explained why incidences of tuberculosis continued to decline even before proven antibiotic treatments took effect. The most likely explanation is the general improvement in living standards of populations in the West during the second half of the nineteenth and first half of the twentieth centuries, including better housing, diet, work conditions, and so forth.16 This makes sense if one considers that the height of the tuberculosis epidemic during the hundred years or more just prior to its pro-tracted decline coincided with the rise and advance of industrialization in Western countries, with its attendant environmental degradation, dramatic shifts of population from rural to urban settings, and untrammeled exploitation of workers, especially children.17 This is further indicated by setbacks to the disease that occurred when living standards temporarily fell in times of crisis or national emergency, such as during the First World War. The bare fact of this decline, more than almost any other aspect, demonstrates that tuberculosis was, and remains today, a “social disease” that depends on more than mere biology for its behavior in a given population.

Yet another efflorescence of tuberculosis’s dependency on societal factors is the romantic reinvention of “consumption” during the early nineteenth century, when it was in very great danger of being nearly perceived as not a disease at all.

One could in fact say that consumption at this time became almost fashionable, when it was imagined that one could simply waste painlessly away into a version of Keats’s “easeful death” (the reality, as patients drowned in their own blood or gasped frantical y from air hunger, was obviously quite different), and apparently some even wished to get sick in order to acquire the delicately pale looks so admired in consumptives and that even today seem to be strived for by bulimic fashion models.18 By the end of the nineteenth century, consumption had lost most of its romantic associations, signified by the mere fact that the more prosaic 94 y Chapter 3

term of “tuberculosis” was coming into greater usage, which was probably a function of the increasingly scientific approach to the disease following Koch’s explication of its bacterial cause and of the fact that poverty was being seen more and more as the natural environmental context of tuberculosis. But until then, consumption touched the lives of many of Europe’s leading artists of the romantic period, including Keats, Percy Shelley, Frédéric Chopin, Robert Schumann, the Brontë sisters, Robert Louis Stevenson (who was a patient at both Davos and Saranac Lake), and, in the United States, Edgar Al en Poe, Ralph Waldo Emerson, and Henry David Thoreau.19 Even though many an artist’s life span was prematurely cut short by the disease, it was widely believed at the time that their genius actually benefited from feverish bouts of activity induced by consumption, and indeed it is entirely possible that the tragically doomed creators’ awareness of their impending demise lent a sense of urgency to their work. Tuberculosis also has a starring role in much of nineteenth-century literature, afflicting the characters of Charles Dickens, Victor Hugo, Anton Chekov, and Fyodor Dostoyevsky. Aside from Mann’s
Magic Mountain
, perhaps the most well-known example is Alexandre Dumas fils’s
The Lady of the Camillias
, in which tuberculosis claims its self-sacrificing heroine, Marguerite Gautier (based on Dumas’ acquaintance with an actual courtesan who died of consumption at age twenty-three, Marie Duplessis).

Dumas’ novel and subsequent play became the inspiration of Giuseppe Verdi’s opera
La Traviata
and in more modern times of the films
Camille
(1936), starring Greta Garbo as Marguerite, and
Moulin Rouge!
(2001), starring Nicole Kidman as Satine, a character clearly based on Marguerite.

An interesting footnote to this cultural aspect of tuberculosis is the disease’s contribution to the vampire legend, particularly in New England. Sometimes, the decomposition of the body after death, which in the case of a disease like tuberculosis is most pronounced in the lungs, can apparently result in blood seeping from the lips, giving the impression that the corpse is still alive and achieves this feat by feasting on victims.20 Added to this would be the suspicious circumstance, especially in an age that imperfectly understood disease contagion, of several members of a family succumbing to consumption within a relatively brief period of time. The allegedly voracious sexual appetite of tuberculosis victims may have also contributed something to the infamously sensual aspect to the legend. From the late eighteenth through to the end of the nineteenth centuries, in Rhode Island, eastern Connecticut, and my home state of Vermont, the graves of both men and women were disinterred in order that a ghastly ritual might be enacted upon the occupants, which was believed to have the power to end their supernatural scourge: this consisted of none other than cutting out the heart (often described as full of blood) of the exhumed victim and burning it to ashes nearby. It seems that nearly all of such “corpse killer” incidents were initi-Tuberculosis y 95