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Tuberculosis, or TB, is an ancient disease that has been with us from the very start. It’s been found in Peruvian mummies, Egyptian mummies, and burial sites that are almost 10,000 years old, at least in DNA form, and it’s still, today, the single deadliest infectious disease, killing almost a million and a half people a year, back on top this year after COVID played the part of Leicester City in 2020. It has infected about a quarter of the world’s population. We’ll come back to that briefly at the end just to cause some existential dread and we’ll have some links for more reading, but forget all that stuff, what we really want to know is how it affected Victorian England, which I think we’ve established is one of this podcast’s favorite eras–in this case, because it was nutty enough to take the symptoms of this disease and essentially proclaim it sexy as all hell while everyone first tried to figure out what it was, then tried to figure out what to do about it. Let’s do a bit of background, keeping in mind, in the US, as a modern ED doc, I’ve seen probably fewer than five cases of TB. If you’re listening or have a background in Global Medicine, feel free to point out stuff I get wrong for a future shout-out! TB is typically caused by mycobacterium tuberculosis, which is a bacterium, and part of a group of seven or eight closely related bacteria, all of which generally cause similar disease. TB is, first off, really slow. Some bacteria replicate in 20 minutes, but TB takes up to a day to replicate. It also needs lots of oxygen. Its cell wall is basically solid fat. It also doesn’t like to move. Because of all those factors, it tends to set up in the lungs–we’re essentially the only victim of this disease–some forms get into livestock, but really it’s all us. It’s able to trick the immune system into bringing it lunch instead of killing it once it’s absorbed, so it creates these giant cavitary lesions and clumps of cells and gunk from us trying to kill the cells called a granuloma generally, and they get quite large. Characteristically it goes for the upper lungs because that’s where the oxygen is richest. Lazy. This is the laziest bacterial disease I’ve ever heard of. E. Coli is clawing its way up the urethra and TB is just sitting there. Complete trash. A relatively high percentage of people don’t even develop active disease if they are infected–90 percent of people who have normal immune systems control the bacterium after infection and develop no symptoms–and although it’s definitely contagious, it takes a fair amount of exposure to catch it–which is not to say it’s not a problem or safe or whatever. It’s more like that picture of the iceberg where most of it is below the water that you see in PowerPoint shows, with a huge number of people infected but not sick, and even when they are, it takes weeks before they start to show symptoms. Because it’s a slow bacterium, TB is likewise a slow disease, usually, with an initial phase that lasts weeks. The ‘post-primary’ phase often lasts for years, outside of what was called ‘galloping consumption’, and outside of other infections like HIV, and primarily consists of a losing battle between the body and the bacteria. You can kill it with antibiotics but it takes, like, four of them, if you’re lucky, and treatment goes on for months. People are intermittently contagious early on, as the body’s immune system tries and usually fails to clear disease. People then devolve into this classic picture of weight loss and what’s called cachexia, with night sweats, and a bloody cough that Hollywood loves. Most of the consequences have to do with destruction of the lungs, but because it is incompletely cleared and can travel through the bloodstream, it can set up and cause granulomas all over. Today, it’s relatively rare in rich countries, so we don’t see it, and thus we don’t care about it as much as we should in general; the WHO still does, and global health does, but there is a whole historical era heavily influenced by tuberculosis–nineteenth century England. There was a bunch of heinous crap in those days, as we’ve covered, and you could die in all sorts of ways, but tuberculosis captured the imagination in a way few other diseases can rival. Starting in the seventeenth century, people noticed that TB was more and more prevalent, and took to calling it ‘consumption’ because it does literally consume patients–people can’t keep up nutritionally and they lose weight to a staggering degree. In the early 1800s, there was a mandate from parliament to track vital statistics, such as mortality rates, cause of death, and so on. This led to a lot of writings about TB overall, with estimates that the disease accounted for anywhere from a fifth to a third of deaths at the time, probably heightening its fame. TB also coincided with our old friend Theophile Hyacinth Laennec’s invention of the stethoscope, which allowed a significant extension of the physical exam, especially of the lungs, where there were numerous findings in TB patients. In combination with growing anatomist studies which we’ve also covered, there was a whole cottage industry of TB prognostication and guesswork, including new names for types of dead tissue–caseating necrosis is a description of dead tissue in the body that looks like cheese, for example–and many autopsy findings to name in TB patients. Because it was so common, many experts had a lot to say about it, always good for fun with an infectious agent before germ theory. Of course the Victorian English, being Victorian English, related TB to what they called ‘constitutional factors’ which was really just cover for a sort of class-based or inherited theory–you’re sick because you’re inferior, the thinking went. This seemed to be the prevalent view in England and northern Europe, for some reason, while TB was regarded as more infectious in the south. Perhaps because the disease was slow, and some percentage cleared the disease even when infected, people looked for explanations other than contagion; as early as 1806, the doctor John Ried said, “the destroying angel, while requiring general retribution for certain deviations from nature, marks particular individuals for primary sacrifice”. This was reinforced with cases like the Bronte family; Emily Bronte, who penned the famous Wuthering Heights, her only novel, published to great acclaim in 1847, was one of the younger sisters. It was her only book, and it was apparently so passionate everyone thought a man wrote it at first. Her whole family died of TB, and rather than look at the fact that they all drank water that drained out of the church graveyard next door or that, you know, TB is contagious, chose to say, oh, well, she was quiet, shy, and retiring, and obviously didn’t have a strong constitution, that must have been passed on to her by her family. Prescriptions for things to strengthen the constitution are thus explained, and, likely, appropriate, because the disease wasn’t curable anyway and ‘medicine’ at the time certainly wasn’t going to cure it! Sea-bathing was a popular one. Horseback riding was popular for hundreds of years–Thomas Sydenham popularized it in the 1600s (sound familiar?), with the dual benefit of exposure to the open air and ‘gentle stimulation of the constitution’. Anything that was stimulating but not over-taxing–swinging, which required little exertion, or sailing were often prescribed. Some rich folks took off on sailboats to Spain. Climate, too–led to examples like Dr. James Clark, who, in the early 1800s, moved to the south of France and eventually set up a clinic in Rome for English people looking to get healthy, and led to the whole sanatorium movement, where specific hospitals or retreats were made in warm climates to help people recover. This is a whole different episode, maybe TB part II, as the sanatorium movement helped grow the hospital movement, and was a look into class differences as well, since pauper ‘sanatoriums’ were quite different from those in the south of France. Fun shout out to Arizona, where Tucson was so popular as a sanatorium destination in the US during TB’s height that people ended up forming tent cities of TB patients outside the city once the multiple sanatoriums filled up. In addition to steps to improve the patient’s constitution, there were any number of direct therapies. There was a ‘consumptive diet’ which included large amounts of fat, which is called suet in the Victorian Era, usually from a specific animal because, as we all know, the best suet is mutton suet. Asses’s milk was very popular for some reason. They tried all sorts of medicines; arsenic and mercury were thankfully used less frequently than quinine–an alkaloid made from Cinchona trees against malaria still–and digitalis, or foxglove, which we’ve also covered. Both of these ‘helped’ by slowing the heart or ‘stopping’ fevers, but really not a great way to treat fever or tachycardia. So anyway that’s some of the medical background at the time, with this illness that is quite fascinating, and kills up to 80% of people that don’t clear it right away and accounts for a quarter, give or take, of deaths in London in the 1800s. The English, though, took this slow-moving epidemic and turned it inside out in a sort of mass cultural delusion which has a few points to discuss. First off, TB was romanticized to a tremendous degree. Emily Bronte was one example of how ‘dying of consumption’ was romanticized by the literary set, since she was the Amy Winehouse of books and only ever published one. Keats, one of the most famous so-called Romantic poets at the beginning of the eighteenth century died of TB. Keats wrote odes to melancholy and the transience of life. Byron, another famous poet and a contemporary of Keats, who wrote ‘she walks in beauty’, a famous pillar of English major life, noted at one point “How pale I look! – I should like, I think, to die of consumption … because then the women would all say, ‘see that poor Byron – how interesting he looks in dying!” Percy Shelly wrote to Keats at one point about this, and basically said, wow, looks like you still have TB, it sure likes us artistic types, doesn’t it? People took the idea that TB was related to constitution and applied it to standards of behavior and beauty in the upper classes; it was sort of assumed that it was a problem among the poor, which it was, but then, to the extent people died of TB among the upper classes, they would relate the infection to ways people were like the poor–linked to foul air, or living in the city when they could live in the country. Many if not all of these written opinions said women were more vulnerable than men because they were ‘indolent and inactive’. Physicians and others with opinions on TB linked lifestyle issues to TB with abandon, including the waltz when it became popular. As anatomists struggled to figure out what the nervous system did or how it worked, there was a whole concept of ‘sensibility’--like, an overactive nervous system–which was the cause of disease, and associated worry that a more refined life was leading to excitation of the nervous system, leading to a whole host of diseases, with TB among them. George Chyne, an English physician at the beginning of the Victorian Era, used this concept to turn health on its head and described what was called the ‘English Malady’--essentially, the price of England’s class, dominance, and wealth was a more excitable nervous system–that’s the sensibility–so that the very reason the English were so successful was the same reason they got sick. To some extent, if you were rich and sick, the sickness was a sign of how amazing you were. This extended to a whole host of maladies. In this setting, being sick with TB, previously romanticized and then linked to a sign of a superior nervous system, became fashionable. The fact that your pulse raced, you got pale and light-headed, and could barely deal with the slightest exertion, was in fact not malnutrition and low oxygen from advancing bacterial illness, but a sign that your nervous system was highly advanced, and actually proof of your high status. Fashion and beauty trends grew out of the above cultural underpinnings at the end of the nineteenth century, and the medical community happily took part. The London Medical and Surgical Journal in 1833, which basically said, in contrast to ‘uglier’ illness, ‘consumption, neither effacing the lines of personal beauty, nor damaging the intellectual functions, tends to exalt the moral habits, and exalt the amiable qualities of a patient’. Keep in mind, this is the description of a progressive bacterial illness that causes giant cheese-like lumps of dead white blood cells and bacteria throughout the body, leading to incessant coughing of blood and almost constant diarrhea until one dies of pneumonia. Fashion trends of the time focused on thinness and pallor as the beauty standards, which TB causes; corsets were used along with lots of other dress accessories to emphasize a slim waist, and make-up trends included rosy cheeks and pale skin. Projecting clavicles and wing-like scapulae were considered attractive, both of them a consequence of severe muscle wasting and what we call cachexia, which today can be seen in conditions that cause severe malnutrition. Writers were fully aware that TB was one of the causes emphasizing standards of beauty; one Victorian beauty essayist wrote that ‘in the last stage of consumption, a lady may exhibit the roses and lilies of youth and health, and be admired for her complexion the day she is to be buried’. It got to the point that medical texts would equate beauty with vulnerability to TB just as we consider high blood pressure a risk for heart disease today. Clothing trends throughout the 1800s were both pushed by this beauty standard and part of the debate over causation, because we all know clothing causes tuberculosis. Through the early 1800s, dresses exposed more skin, especially in the back, which was related to the scapula fashion, but was then attacked by many physicians as dangerous because we all know you catch cold when you go outside without suitable clothing. There’s so much discussion of wing-like shoulder blades in Victorian writing, either in favor or in disapproval. Women also stopped using flannel underwear which some physicians thought was quite dangerous. Lastly, corsets, which emphasized thin waists, were a huge point of debate, as they restricted both activity and, you know, breathing. I think it’s probably a great idea for the three of us to go on at length about fashion trends, right? There’s also a phenomenon called ‘tight-lacing’ which was prominent in use of corsets, by no means universal it looks like but common, that was condemned by many physicians as causative. Long trains on dresses were also blamed for kicking up dust that affected the lungs as women walked along dirt streets in London. This only intensified when Robert Koch isolated and identified the bacterium in the 1880s as the cause, at which point, other physicians said well the skirts must increase passage of the bacterium. I think it’s fair to say that men suffered equally from fashion trends when the voluminous beards of the late Victorian Era were largely attacked for the number of bacteria they held; Edwin Bowers, the doctor who pioneered reflexology, proved that even a blind squirrel finds a nut now and then when he said that ‘there is no way of knowing the number of bacteria and noxious germs that may lurk in the Amazonian jungles of a well-whiskered face, but their number must be legion’, blaming whiskers for tuberculosis, whooping cough, diphtheria, measles, and scarlet fever, to name a few. This led to a new clean-shaven fashion trend, especially among doctors, which is sad, because there are literally no beards like late nineteenth-century beards. Tuberculosis gradually declined in England for no good reason, really. It spread through the US as well a bit later, and, as I said, probably has fodder for another couple episodes with regards to the history it represents. Since I always like to end on an up note, just keep in mind that TB is deadlier than ever; most cases at this point occur in developing nations in Africa and Asia. There is a strong link to HIV, which potentiates infection. Because it’s so difficult to treat, we’re up to about 50 thousand cases a year of so-called XDR-TB, which is the X-games version of MDR-TB, or multi-drug resistant TB. The worst strains are resistant to multiple antibiotics, and are incredibly hard to treat. Our only good vaccine has a ton of real side effects and is only, right now, used in children and people with latent disease, I believe. Good times ahead with this still incredibly active disease. At least we can all die beautiful. References
Aaron Silver Fox Doc
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