THE IMPACT OF TUBERCULOSIS ON HISTORY. LITERATURE AND ART H. D. CHALKE If men could learn from history, what lessons it might teach us! S, T. COLERIDGE INTRODUCTION DISEASE has had an incalculable influence on the history of mankind. The earliest records tell of plagues and pestilences which devastated whole countries and had profound effects on social structure, contributing to unrest, famine, migration and wars. But history is the essence of unnumerable biographies'and so individual ill- health, both mental and physical, has had a great impact on world events, and on the Arts-literature, poetry, painting and music. a study of the biographies of the famous shows how often they have been dogged by illness of the mind or body, and it is interesting to speculate as to the effect this may have had on their outlook, productivity or scholarship. Consider also what those geniuses in the world of poetry or music who died young might have achieved had they lived! There is no doubt, either, that illness and early death of the parents plays a part in determining the habits and character of the children. Tuberculosis when it was in its epidemic phases in this country exemplifies this The story of tuberculosis gives us, perhaps, as good a picture as any of the impact of disease on life and culture. Apart from leprosy, western civilization has known no communicable disease which may run such a protracted course, affecting almost any part of the body and giving rise to such long periods of ill-health and disablement HISTORY 3 o No one can tell when the tubercle bacillus first became a parasite of man,or w infection began. There are at least some grounds for the supposition that it was of bovine origin, but whatever its source, man and his animals seem to have been affected a very long time ago. As a communicable disease, its spread would have been restricted until isolated groups of people began to adopt a ider community existence, sharing their dwellings with the sheep, pigs and cattle that had become domesticated(? c. 12, 00o years ago), and extending their outside contacts. Movement farther afield as trade routes opened up(the horse, domesticated much later than the other animals, helped to make this possible and the growth of centres of barter at the junctions of these routes and at the minals, would aid the passage of infection. The human drift in search of and better pasture was intensified as population increased; and with r numbers at risk, in the less hospitable climates to the west and north in
THE IMPACT OF TUBERCULOSIS ON HISTORY, LITERATURE AND ART by H. D. CHALKE If men could learn from history, what lessons it might teach us! S. T. COLERIDGE INTRODUCTION DISEASE has had an incalculable influence on the history of mankind. The earliest records tell of plagues and pestilences which devastated whole countries and had profound effects on social structure, contributing to unrest, famine, migration and wars. But 'history is the essence of unnumerable biographies' and so individual illhealth, both mental and physical, has had a great impact on world events, and on the Arts-literature, poetry, painting and music. A study of the biographies of the famous shows how often they have been dogged by illness of the mind or body, and it is interesting to speculate as to the effect this may have had on their outlook, productivity or scholarship. Consider also what those geniuses in the world of poetry or music who died young might have achieved had they lived! There is no doubt, either, that illness and early death of the parents plays a part in determining the habits and character of the children. Tuberculosis when it was in its epidemic phases in this country exemplifies this. The story of tuberculosis gives us, perhaps, as good a picture as any of the impact of disease on life and culture. Apart from leprosy, western civilization has known no communicable disease which may run such a protracted course, affecting almost any part of the body and giving rise to such long periods of ill-health and disablement. HISTORY No one can tell when the tubercle bacillus first became a parasite of man, or how infection began. There are at least some grounds for the supposition that it was of bovine origin, but whatever its source, man and his animals seem to have been affected a very long time ago. As a communicable disease, its spread would have been restricted until isolated groups of people began to adopt a wider community existence, sharing their dwellings with the sheep, pigs and cattle that had become domesticated (? c. 12,000 years ago), and extending their outside contacts. Movement farther afield as trade routes opened up (the horse, domesticated much later than the other animals, helped to make this possible) and the growth of centres of barter at the junctions of these routes and at the sea terminals, would aid the passage of infection. The human drift in search of game and better pasture was intensified as population increased; and with greater numbers at risk, in the less hospitable climates to the west and north in 30I
H chalke the wake of the retreating ice, more and more people would be prone to pulmonary complaints About Io,000 B.C. Neolithic man was moving into Europe, leading a community life in lake dwellings. It seems that horseflesh was no longer used as a human food (the horse was not apparently as subject to tuberculosis as the cow or pig which were eaten in its place), and cow s milk became part of the diet. The thoracic vertebrae seen in a Neolithic skeleton found at Heidelberg, show collapse, strongly suggestive of tuberculous infection The basins of the Nile, and the Tigris and Euphrates, cradled civilization in 5000-3000 B.C. It is understood that tuberculosis is not mentioned in the ebers Papyrus, nor in the code of laws of Hammurabi of Babylon (2250 B.C. )(Burke Elliot Smith found evidence of tuberculosis in five out of 10, 000 egyptian skeletons, the earliest dated 3500 B.C. and, quite recently, palaeopathology has revealed spinal caries and a psoas abscess in a mummy of the XxIst lynasty(G 1000 B.C. ) But the ancient Egyptians left no accounts of tuberculosis he standard of health was high, as Herodotus(c. 400 B.C. ) the traveller and descriptive writer, confirmed-though some centuries later. Neither the Old nor the New Testaments give acceptable information of a disease such as the respiratory tuberculosis of modern times(Fraser). It is not to be found in the Mosaic Code, but the description in the Talmud of caseous nodules in the lungs of animals is noteworthy. Frazer(The Golden bough)says that the hindoos in Vedic times(I500 B. c )sang: O consumption fy away with the Blue jay but 'consumptionin relation to those days may be a vague appellation. Did they-if indeed they knew phthisis in that era-receive the infection from the East or from the West? The latter appears to be the more probable in view of the early lines of communication between the two. It must be noted that, according to francis, tuberculosis was common in domesticated wild elephants in ancient Hindoo times a treatise on animal diseases written in A D. 420 describes cough and emacia tion, or consumption, as a serious disease of cattle A tomb in Asia Minor, of a child of four and a half years dying in the third century B. C, records death from disease of the testicles, foot and intestines, with wasting of other parts: I have left the hated consumption as a heritage to my survivors'(Meinecke). The move ment of herds of Lombardy cattle across Europe which commenced in the thirteenth century, and steadily increased, could conceivably have been linked with the high incidence of scrofula and other manifestations of bovine tuber. culosis in man which continued until the present century Recent Discoveries Theories about the be gs of tuberculosis as a disease of man, and suppositions as to its first must be modified in the light of recent find- ings in palaeopathology, more accurate determination of the age of human and animal remains which carbon-I4 estimation has made possible. Of
H. D. Chalke the wake of the retreating ice, more and more people would be prone to pulmonary complaints. About I0,000 B.C. Neolithic man was moving into Europe, by 5000 B.C. leading a community life in lake dwellings. It seems that horseflesh was no longer used as a human food (the horse was not apparently as subject to tuberculosis as the cow or pig which were eaten in its place), and cow's milk became part of the diet. The thoracic vertebrae seen in a Neolithic skeleton found at Heidelberg, show collapse, strongly suggestive of tuberculous infection. The basins of the Nile, and the Tigris and Euphrates, cradled civilization in 5000-3000 B.C. It is understood that tuberculosis is not mentioned in the Ebers Papyrus, nor in the code of laws of Hammurabi of Babylon (2250 B.C.) (Burke). Elliot Smith found evidence of tuberculosis in five out of I0,000 Egyptian skeletons, the earliest dated 3500 B.C. and, quite recently, palaeopathology has revealed spinal caries and a psoas abscess in a mummy of the XXIst dynasty (c. I000 B.C.). But the ancient Egyptians left no accounts of tuberculosis: the standard of health was high, as Herodotus (c. 400 B.C.), the traveller and descriptive writer, confirmed-though some centuries later. Neither the Old nor the New Testaments give acceptable information of a disease such as the respiratory tuberculosis of modern times (Fraser). It is not to be found in the Mosaic Code, but the description in the Talmud of caseous nodules in the lungs of animals is noteworthy. Frazer (The Golden Bough) says that the Hindoos in Vedic times (I500 B.C.) sang: 'O consumption fly away with the Blue Jay': but 'consumption' in relation to those days may be a vague appellation. Did they-if indeed they knew phthisis in that era-receive the infection from the East or from the West? The latter appears to be the more probable in view of the early lines of communication between the two. It must be noted that, according to Francis, tuberculosis was common in domesticated wild elephants in ancient Hindoo times. Cattle A treatise on animal diseases written in A.D. 420 describes cough and emaciation, or consumption, as a serious disease of cattle. A tomb in Asia Minor, of a child offour and a half years dying in the third century B.C., records death from disease of the testicles, foot and intestines, with wasting of other parts: 'I have left the hated consumption as a heritage to my survivors' (Meinecke). The movement of herds of Lombardy cattle across Europe which commenced in the thirteenth century, and steadily increased, could conceivably have been linked with the high incidence of scrofula and other manifestations of bovine tuberculosis in man which continued until the present century. Recent Discoveries Theories about the beginnings of tuberculosis as a disease of man, and suppositions as to its first vectors, must be modified in the light of recent findings in palaeopathology, and the more accurate determination of the age of human and animal remains which carbon-14 estimation has made possible. Of 302
The Impact of Tuberculosis on History, Literature and Art outstanding interest in this connexion is the discovery of Pott,s Disease, and rib deformity believed to be evidence of tuberculous disease of the chest, in a Californian skeleton(c. 400 B. C )(Roney It is said that america had no aborigines, and that its first men crossed fron Asia after the palaeolithic period(c. I5,000-10,00o B.C. ) when the two continents had only a short stretch of sea between them. After that time they appear to have been cut off from the old world for many millennia. They had no domestic animals(the bison was untameable), and there was probably negligible tribal contact in a continent so vast, and so sparsely peopled. Was the disease already present among those who crossed from Asia to Alaska, and was the infection brought by the white man something they had known before? Among the first British allusions are those by Taliesin, the sixth century Welsh poet('phthysis is one of the three tedious diseases), and the Physicians of Myddfai who gave mouse dung for blood-spitting(Red Book of Hergest, I3th century). Evidence of probable tuberculosis in early Saxon skeletons is discussed by brothwell Thus, whilst there is little doubt about the antiquity of non-pulmonary mani- festations the extent and distribution of respiratory tuberculosis in ancient times is far more speculative. Yet, one wonders what part it may have played in the demise of those ancient civilizations whose history is lost. The balance of evidence suggests, however, that originally, phthisis was not an important disease of hot climates But there are more authentic facts about tuberculosis in classical antiquity when phthisis-a wasting sickness with cough--must have been common. It was his writings have been quoted by doctors ever since, not always accurately, and often with the doubtful assumption--because of the frequent references to it in his works-that tuberculosis was very widely prevalent at that time. Its infectivity was suspected even in those remote days at least 2, 200 years before Koch discovered the organism: Aristotle(d. 322 B.C. )wondered why those in contact with sufferers took phthisis, but did not do so after contact with dropsy. Saxon and medieval britain* Little is known about phthisis in Saxon and Medieval England, an epoch not remarkable for advances in medical knowledge. The killers of the age were epidemic diseases such as plague, typhus, smallpox and the sweating sickness, which removed many of those who might have succumbed to the more chronic phthisis. The country was sparsely populated, t travel was limited, and indus- trialization had not begun. but although there is nothing to suggest that consumption was a major disease, it seems that leprosy was Brought to Europe by the Army of Pompey in 61 B.C., by A.D. 620, according to the chroniclers, it was common in England: in the thirteenth century soldiers returning from the Crusades brought more infection with them, but in the next 3oo years it slowly caminations of ago skeletons in the Roman-British cemetery at York-the largest an gd Roman fork, H.M.S. O, 1962 t Population: 1066: 31 million; 1500: 5 million; 1625: 7 million; 1714: 9 million; 1837: 26 million. 303
The Impact of Tuberculosis on History, Literature and Art outstanding interest in this connexion is the discovery of Pott's Disease, and rib deformity believed to be evidence of tuberculous disease of the chest, in a Californian skeleton (c. 400 B.C.) (Roney). It is said that America had no aborigines, and that its first men crossed from Asia after the palaeolithic period (c. 15,000-I0,000 B.C.) when the two continents had only a short stretch ofsea between them. After that time they appear to have been cut off from the Old World for many millennia. They had no domestic animals (the bison was untameable), and there was probably negligible tribal contact in a continent so vast, and so sparsely peopled. Was the disease already present among those who crossed from Asia to Alaska, and was the infection brought by the white man something they had known before? Among the first British allusions are those by Taliesin, the sixth century Welsh poet ('phthysis is one of the three tedious diseases'), and the Physicians of Myddfai who gave mouse dung for blood-spitting (Red Book of Hergest, I 3th century). Evidence of probable tuberculosis in early Saxon skeletons is discussed by Brothwell. Thus, whilst there is little doubt about the antiquity of non-pulmonary manifestations the extent and distribution of respiratory tuberculosis in ancient times is far more speculative. Yet, one wonders what part it may have played in the demise ofthose ancient civilizations whose history is lost. The balance ofevidence suggests, however, that originally, phthisis was not an important disease of hot climates. But there are more authentic facts about tuberculosis in classical antiquity, when phthisis-a wasting sickness with cough-must have been common. It was Hippocrates (400 B.C.) who gave the first clear description of consumption, and his writings have been quoted by doctors ever since, not always accurately, and often with the doubtful assumption-because of the frequent references to it in his works-that tuberculosis was very widely prevalent at that time. Its infectivity was suspected even in those remote days at least 2,200 years before Koch discovered the organism: Aristotle (d. 322 B.C.) wondered why those in contact with sufferers took phthisis, but did not do so after contact with dropsy. Saxon and Medieval Britain* Little is known about phthisis in Saxon and Medieval England, an epoch not remarkable for advances in medical knowledge. The killers of the age were epidemic diseases such as plague, typhus, smallpox and the sweating sickness, which removed many of those who might have succumbed to the more chronic phthisis. The country was sparsely populated,t travel was limited, and industrialization had not begun. But although there is nothing to suggest that consumption was a major disease, it seems that leprosy was. Brought to Europe by the Army of Pompey in 6I B.C., by A.D. 620, according to the chroniclers, it was common in England: in the thirteenth century soldiers returning from the Crusades brought more infection with them, but in the next 300 years it slowly * Recent examinations of 290 skeletons in the Roman-British cemetery at York-'the largest and most significant find of its kind ever made'-yielded no evidence of tuberculous disease. Eburacum, Roman rork, H.M.S.O., I962, !. t Population: Io66: 3j million; 1500: 5 million; I625: 7 million; I 714: 9 million; I837: 26 milion. 303
cousin, consumption, which may now be following the same path, by its first diminished and eventually disappeared altogether, to be replaced Scrofula-the King's Evil Thereis much more to be learned about a non-pulmonary form of tuberculosis, tuberculous adenitis or scrofula(from scrofa, a sow"because these animals are subject to it'), which seems to have been abundant at that time. Supposed to be curable by the touch of a king, it was called the King 's Evil. william of Malmes- bury, the eleventh-century historian, records the royal touch as early as Edward the Confessor's reign. The physician to the Court of Edward II, John of Gaddes den, who wrote Rosa Anglica in 1320, exhorted sufferers from scrofula to apply for the Royal Touch if sovereign remedies'such as the blood of a weasel or dove's dung did not bring speedy improvement. Pepys and Evelyn give graphic descriptions of the ceremonies during Stuart times, when the press of people was so great that many were crushed to death: John Brown, surgeon to Charle I I, calculated that the king touched nearly 100,ooo between 166o and 1682 Brown believed deaths from scrofula to be 'the highest ever, an increase he associated with the kings absence. Richard Wiseman, Serjeant Chyrurgeon to Charles II, noted that the blood of Charles i gathered after his execution on chips and handkerchiefs' had the same healing powers Dr. Richard Morton, I 689, who added much to knowledge of tuberculd separated scrofula into tuberculous and non-tuberculous forms; the tendency to spontaneous improvement to which he drew attention, and inaccuracy of diagnosis, must have accounted for many of the miraculous cures. Misconcep- tions about the aetiology of this complaint lasted a long time, and confused the new pathology of tuberculosis so ably demonstrated by Matthew Baillie a century later.(As late as 189I, in a Manual of domestic Medicine by 'Physicians nd Surgeons of the Principal London Hospitals'it is stated categorically that scrofula though often confounded with tuberculosis is quite distinct from it despite the occasional similarity of symptoms. But despite diagnostic confusion, the evidence suggests a high prevalence of disease of bovine origin at that time. There is a descriptive passage in Macbeth: Tis called the evil... strangely visited people all swoln and ulcerous, pitiful to the eye, the mere despair of Samuel Johnson was a sufferer Queen Anne, the last English monarch to practise the Royal Touch, touched him when he was five years old, apparently without benefit. Johnson is an example of a genius whose characteristics should be considered in relation to his disability. He had a huge body, much disfigured by scrofulous scars, and a mighty mind, but ' disease of the spirits'; in his own words:"There are perhaps few conditions more to be pitied than that of an active and elevated mind labouring under the weight of a distempered body. THE GROWTH OF PHTHISIS IN BRITAIN The student of epidemiological history is ha amper d by the absence of accurate statistical facts. bills of mortality began in London in I532, a plague 304
H. D. Chalke diminished and eventually disappeared altogether, to be replaced by its first cousin, consumption, which may now be following the same path. Scrofula-the King's Evil There is much more to be learned about a non-pulmonary form oftuberculosis, tuberculous adenitis or scrofula (from scrofa, a sow 'because these animals are subject to it'), which seems to have been abundant at that time. Supposed to be curable by the touch ofa king, it was called the King's Evil. William of Malmesbury, the eleventh-century historian, records the royal touch as early as Edward the Confessor's reign. The physician to the Court of Edward II, John of Gaddesden, who wrote Rosa Anglica in 1320, exhorted sufferers from scrofula to apply for the Royal Touch if 'sovereign remedies' such as the blood of a weasel or dove's dung did not bring speedy improvement. Pepys and Evelyn give graphic descriptions of the ceremonies during Stuart times, when the press of people was so great that many were crushed to death: John Brown, surgeon to Charles II, calculated that the king touched nearly ioo,ooo between i66o and I682. Brown believed deaths from scrofula to be 'the highest ever', an increase he associated with the king's absence. Richard Wiseman, Serjeant Chyrurgeon to Charles II, noted that the blood of Charles I gathered after his execution 'on chips and handkerchiefs' had the same healing powers. Dr. Richard Morton, I689, who added much to knowledge of tuberculosis, separated scrofula into tuberculous and non-tuberculous forms; the tendency to spontaneous improvement to which he drew attention, and inaccuracy of diagnosis, must have accounted for many of the miraculous cures. Misconceptions about the aetiology of this complaint lasted a long time, and confused the new pathology of tuberculosis so ably demonstrated by Matthew Baillie a century later. (As late as I89I, in a Manual of Domestic Medicine by 'Physicians and Surgeons of the Principal London Hospitals' it is stated categorically that scrofula though often confounded with tuberculosis is quite distinct from it despite the occasional similarity of symptoms.) But despite diagnostic confusion, the evidence suggests a high prevalence of disease of bovine origin at that time. There is a descriptive passage in Macbeth: "Tis called the evil . . . strangely visited people all swoln and ulcerous, pitiful to the eye, the mere despair of surgery.' Samuel Johnson was a sufferer. Queen Anne, the last English monarch to practise the Royal Touch, touched him when he was five years old, apparently without benefit. Johnson is an example of a genius whose characteristics should be considered in relation to his disability. He had a huge body, much disfigured by scrofulous scars, and a mighty mind, but 'disease of the spirits'; in his own words: 'There are perhaps few conditions more to be pitied than that of an active and elevated mind labouring under the weight of a distempered body.' THE GROWTH OF PHTHISIS IN BRITAIN The student of epidemiological history is hampered by the absence of accurate statistical facts. Bills of Mortality began in London in 1532, a plague 304
The Impact of Tuberculosis on History, Literature and Art year, and continued intermittently to begin with until I836, when the births nd Deaths Registration Act was passed. Notification of all forms of tuberculosis is as recent as 1912. The Bills gave only the proportionate mortality and not the death-rate per unit of population: the recorded cause of death was that given by the old women who acted as searchers, who have been described as drunken, venal and ignorant, easily bribed and ready to write'consumption'when paid to conceal the presence of plague. Despite these inaccuracies, much can be comment that the searchers could not tell whether emaciation and leanness were from phthisis or hectick fever. By 1799 consumption was given as the cause of one out of every four deaths in London. w. Woolcombe, M. D, in 18r8 published a masterly analysis of the data and also of figures obtained from parish registers and public dispensary returns. He found that the absolute and relative mortality from consumption had increased in many parts of the country since 1700"the rate was so high as almost to exceed belief. In a secluded Shropshire village, for example, the parish registers revealed a comparative mortality of and rs rose to one three. In other places, also, local epidemics were occurring. It seems that this was an epidemic phase in England, which showed little decline until the I83os CAUSATIVE FACTORS What were the factors contributing to this spread of tuberculosis? There are many possibilities. The Restoration brought profound changes in the English way of life. The country became more prosperous, there was an improvement in the state of society and travel became easier; yet, within a century misery and wretchedness abounded and 1, 200, 000 of the 8, 800, ooo inhabitants were receiving parish relief. The influx of susceptibles from rural England to London after the poore plague, consisted chiefly of persons ' at that period of life deemed most liable to invasion of phthisical disease'. For a time, we are told, there was a large number of weakly children reared who ' in a less improved state of society must have perished in infancy,. If it is agreed that the key to adult tuberculosis is to be found in childhood infection, the infants of that time may have laid the foun dations of the adult consumption which later on spread over Britain Race and environ Housing, nutrition, habits, overcrowding, income, climate, occupation, psychological factors and racial susceptibility have time and again been cited as influences affecting phthisis morbidity and mortality, but as yet the role of the individual items has not been ascertained with any accuracy. The skein has not been unravelled. It will not be overlooked that the rise in tuberculosis started long before the Industrial Revolution of the I78os, and began to fall at a time when hygiene and sanitation were of a low order, cholera and typhoid menaced the country and maternal and infant deaths were excessive. Life was harsh and cheap: the only legislative welfare service was the Poor Lay 305
The Impact of Tuberculosis on History, Literature and Art year, and continued intermittently to begin with until I836, when the Births and Deaths Registration Act was passed. Notification of all forms of tuberculosis is as recent as I9 I 2. The Bills gave only the proportionate mortality and not the death-rate per unit of population: the recorded cause of death was that given by the old women who acted as searchers, who have been described as drunken, venal and ignorant, easily bribed and ready to write 'consumption' when paid to conceal the presence of plague. Despite these inaccuracies, much can be deduced from the Bills. John Graunt (I662), a pioneer statistician, made the comment that the searchers could not tell whether emaciation and leanness were from phthisis or 'hectick fever'. By I799 consumption was given as the cause of one out of every four deaths in London. W. Woolcombe, M.D., in I8I8 published a masterly analysis of the data and also offigures obtained from parish registers and public dispensary returns. He found that the absolute and relative mortality from consumption had increased in many parts of the country since I 700-'the rate was so high as almost to exceed belief'. In a secluded Shropshire village, for example, the parish registers revealed a comparative mortality of one in six between 1750 and 1759, which in the next ten years rose to one in three. In other places, also, local epidemics were occurring. It seems that this was an epidemic phase in England, which showed little decline until the I83os. CAUSATIVE FACTORS What were the factors contributing to this spread of tuberculosis? There are many possibilities. The Restoration brought profound changes in the English way of life. The country became more prosperous, there was an improvement in the state ofsociety and travel became easier; yet, within a century misery and wretchedness abounded and I,200,000 of the 8,8oo,ooo inhabitants were receiving parish relief. The influx of susceptibles from rural England to London after the 'poore plague', consisted chiefly of persons 'at that period of life deemed most liable to invasion ofphthisical disease'. For a time, we are told, there was a large number of weakly children reared who 'in a less improved state of society must have perished in infancy'. If it is agreed that the key to adult tuberculosis is to be found in childhood infection, the infants of that time may have laid the foundations of the adult consumption which later on spread over Britain. Race and Environment Housing, nutrition, habits, overcrowding, income, climate, occupation, psychological factors and racial susceptibility have time and again been cited as influences affecting phthisis morbidity and mortality, but as yet the role of the individual items has not been ascertained with any accuracy. The skein has not been unravelled. It will not be overlooked that the rise in tuberculosis started long before the Industrial Revolution of the 1780s, and began to fall at a time when hygiene and sanitation were of a low order, cholera and typhoid menaced the country, and maternal and infant deaths were excessive. Life was harsh and cheap: the only legislative welfare service was the Poor Law. 305
H.D. chalke Brownlee, commenting on the rise and fall of epidemics, thought that germs may undergo mutation and that the generation of an epidemic depended on the right mutation, corresponding with a suitable disposition of the population at risk. Today, can much more be said? Young in a signal contribution to medical literature(1815) showed how the phthisis mortality varied in different parts of Britain and in other countries There may be significance in the fact that the more isolated places--parts of Scotland. wales and Ireland- -do not a to have met tuberculosis in epidemic form until more than 1o0 years after urban England. The decline in en corre spondingly delayed. In places such as Nepal and Puerto Rico, tuberculosis is in epidemic form today. (The mass radiography of Gurkha soldiers reveals an incidence of 14 8 per 1, 0oo )Brownlee found that in Pembrokeshire a line could be drawn across the county, above it the tuber culosis rate was high, below it, low. In the north the people are Welsh of beran stock: those to the south are the descendants of the normans. The anthropological characters are still evident, the place-names and language are different. Mining(coal, lead, slate, etc. ) under-nourishment and tuberculous cattle,weighted the scales against the susceptible welsh In due course some influence comes into action, which Newsholme thought prevents the excessive tuberculosis which an adverse environment evokes. He cited Ireland, where housing improvements did not retard the rising phthisis mortality; for some time in the U.S. A. it remained excessive, despite better living conditions-a higherracialresistance had not yet been acquired, and as happened to many other races, the irish were not yet able to withstand the massive and repeated infection which beset them in urban life. The wider question of the origins, antiquity and recent incidence of tuberculosis in the several races of the Americas, New Zealand, Africa and eastern countries is of great interest, but it is too large and complex to be discussed here. More primitive peoples may be suffering from exposure to a new infection, or an old infection reintroduced, to which immunity has been lost. They are fortunate in having new methods of prevention and treatment to aid them, and in being able to take advantage of the experiences of those countries, which after centuries of struggle, are at last coming to terms with tuberculosis OTHER SOURCES OF INFORMATION Q Fortunately, there are sources of information ancillary to the statistical, which ay be sought in contemporary literature, biography and art: some of these have been mentioned already as the sole record of the position many centuries ago; others, of more modern times, must be reviewed in a little more detail, in particular literature-biography, autobiography and fiction--from the begin ning of the eighteenth century Shakespeare(died 1 616)was exceptionally well-informed on medical matters and it is difficult to find any great author, not a doctor, who so often refers to the healing art(Bucknill). His infrequent allusion to 'consumptionand the rare references to its classical symptoms are, therefore, pointers to the impact of this 3o6
H. D. Chalke Brownlee, commenting on the rise and fall ofepidemics, thought that germs may undergo mutation and that the generation of an epidemic depended on the right mutation, corresponding with a suitable disposition of the population at risk. Today, can much more be said? Young in a signal contribution to medical literature (I8I5) showed how the phthisis mortality varied in different parts of Britain and in other countries. There may be significance in the fact that the more isolated places-parts of Scotland, Wales and Ireland-do not appear to have met tuberculosis in epidemic form until more than ioo years after urban England. The decline in these countries has been correspondingly delayed. In places such as Nepal and Puerto Rico, tuberculosis is in epidemic form today. (The mass radiography of Gurkha soldiers reveals an incidence of I4-8 per i,ooo.) Brownlee found that in Pembrokeshire a line could be drawn across the county, above it the tuberculosis rate was high, below it, low. In the north the people are Welsh of Iberian stock; those to the south are the descendants of the Normans. The anthropological characters are still evident, the place-names and language are different. Mining (coal, lead, slate, etc.), under-nourishment and tuberculous cattle, weighted the scales against the susceptible Welsh. In due course some influence comes into action, which Newsholme thought prevents the excessive tuberculosis which an adverse environment evokes. He cited Ireland, where housing improvements did not retard the rising phthisis mortality; for some time in the U.S.A. it remained excessive, despite better living conditions-a higher racial resistance had not yet been acquired, and as happened to many other races, the Irish were not yet able to withstand the massive and repeated infection which beset them in urban life. The wider question of the origins, antiquity and recent incidence of tuberculosis in the several races of the Americas, New Zealand, Africa and eastern countries is of great interest, but it is too large and complex to be discussed here. More primitive peoples may be suffering from exposure to a new infection, or an old infection reintroduced, to which immunity has been lost. They are fortunate in having new methods of prevention and treatment to aid them, and in being able to take advantage of the experiences of those countries, which after centuries of struggle, are at last coming to terms with tuberculosis. OTHER SOURCES OF INFORMATION Fortunately, there are sources ofinformation ancillary to the statistical, which may be sought in contemporary literature, biography and art: some of these have been mentioned already as the sole record of the position many centuries ago; others, of more modern times, must be reviewed in a little more detail, in particular literature-biography, autobiography and fiction-from the beginning of the eighteenth century. Shakespeare (died I6I6) was exceptionally well-informed on medical matters and it is difficult to find any great author, not a doctor, who so often refers to the healing art (Bucknill). His infrequent allusion to 'consumption' and the rare references to its classical symptoms are, therefore, pointers to the impact of this 306
The Impact of T uberculosis on History, Literature and Art disease on the life of his times. This lends support to the view that it was not until after his death that the sharp rise in incidence began. It is true that wasting disease,,'phtisick'(phthisis), rotten lungs, wheezing lungs'and "lethargiesare spoken of in many of his plays, but the words seem to be applied indefinitely, relating to syphilis, ague and other conditions as well as to tuberculous disease a rascally phtisick so troubles me.. I have a rheum in such an ache ny bones -Troilus and Cressida. sumption sow in hollow bones of m I was told you were in consumption -Much Ado About Nothi Side stitches that shall pen thy breath up -The Tempest most incident to maidens. -The Winters Tale After 1700, novelists allude to symptoms and effects more often and descrip tions of the pale heroine languishing in a decline are not hard to find, but usually the writers avoided the dreaded word consumption. Consumptive children, said a writerina popular work of the nineties, are the novelists'favourite little heroes and heroines, who appear like fairies to gladden the hearts of parents and friends for a short season. Victorian song writers also liked them. It is only in the past few decades, as the stigma has slowly disappeared, that tuber culosis has been named with any frequence; nowadays no details are spared of the early symptoms, the rigours of sanatorium treatment, and the dramati episode of the sudden haemoptysis. E.g. The Plague and 1, Betty Macdonald The Print Petticoat, Lucilla Andrews; Three Comrades, Erich Remarque. Swift, in The Tale of a Tub (168g), does describe languishing consumption, whose tainted breath destroys unhappy infants; so does Fielding in Tom Jones (174o). Samuel Richardson, the author of the first English novel(I74o)makes Clarissa, in the book of that name, die of a decline, aged nineteen. Elaine in The Morte d'Arthur of Malory(14o)may well have been the first young lady of he English romance to have been so afflicted. The decline associated with the emotional disturbances of an unhappy love affair was a popular theme with Victorian novelists like the Brontes and Jane Austen, who were themselves tuberculous. You will remember Helen Burns in Jane Eyre(1847)who died of semi-starvation and neglected colds; and"the vanished bloom and wasted flesh n Shirley(1849), also written by Charlotte Bronte, about her sister. There were many more who faded like any fower in drought,. The closing scenes were ually happy, quite unlike those occurring in real life(there are no major crises in Jane Austens works and no deaths). In considering these characters, it is to be noted that many authorities today believe that emotional and mental upsets act as exciting causes of active tuberculosis, and Kissen and others peak of a break in the "love- link'in this connexion. One other youthful victim should be mentioned, poor Smike in Nicholas Nickleby, with sunken eyes too bright and hollow cheeks too flushed Smollet, who had no success as a doctor, wrote admirably, despite his ill- temper and vindictive nature: he had tuberculosis himself and wrote of it in many of his books. This passage is from Roderick Random(1748), about a sick parade at se one(sailor)complained of a pleuritic stitch and spitting of
The Impact of Tuberculosis on History, Literature and Art disease on the life of his times. This lends support to the view that it was not until after his death that the sharp rise in incidence began. It is true that 'wasting disease', 'phtisick' (phthisis), 'rotten lungs', 'wheezing lungs' and 'lethargies' are spoken of in many of his plays, but the words seem to be applied indefinitely, relating to syphilis, ague and other conditions as well as to tuberculous disease: ... a rascally phtisick so troubles me ... I have a rheum in my eye too, and such an ache in my bones.-Troilus and Cressida. Consumption sow in hollow bones of man.-Timon of Athens. I was told you were in consumption.-Much Ado About Nothing. Side stitches that shall pen thy breath up.-The Tempest. Pale primroses that die unmarried ... most incident to maidens.-The Winter's Tale. After I 700, novelists allude to symptoms and effects more often and descriptions of the pale heroine languishing in a decline are not hard to find, but usually the writers avoided the dreaded word 'consumption'. Consumptive children, said a writer in a popular work ofthe nineties, are the novelists' favourite little heroes and heroines, who appear like fairies to gladden the hearts ofparents and friends for a short season. Victorian song writers also liked them. It is only in the past few decades, as the stigma has slowly disappeared, that tuberculosis has been named with any frequence; nowadays no details are spared of the early symptoms, the rigours of sanatorium treatment, and the dramatic episode of the sudden haemoptysis. (E.g. The Plague and I, Betty Macdonald; The Print Petticoat, Lucilla Andrews; Three Comrades, Erich Remarque.) Swift, in The Tale of a Tub (I689), does describe languishing consumption, 'whose tainted breath destroys unhappy infants'; so does Fielding in Tom jones (I 740). Samuel Richardson, the author of the first English novel (I 740) makes Clarissa, in the book of that name, die of a decline, aged nineteen. Elaine in The Morte d'Arthur of Malory (1470) may well have been the first young lady of the English romance to have been so afflicted. The decline associated with the emotional disturbances of an unhappy love affair was a popular theme with Victorian novelists like the Brontes and Jane Austen, who were themselves tuberculous. You will remember Helen Burns in jane Eyre (I847) who died of semi-starvation and neglected colds; and 'the vanished bloom and wasted flesh' in Shirley (I849), also written by Charlotte Bronte, about her sister. There were many more who 'faded like any flower in drought'. The closing scenes were usually happy, quite unlike those occurring in real life (there are no major crises in Jane Austen's works and no deaths). In considering these characters, it is to be noted that many authorities today believe that emotional and mental upsets act as exciting causes of active tuberculosis, and Kissen and others speak of a break in the 'love-link' in this connexion. One other youthful victim should be mentioned, poor Smike in Nicholas Nickleby, 'with sunken eyes too bright and hollow cheeks too flushed'. Smollet, who had no success as a doctor, wrote admirably, despite his illtemper and vindictive nature: he had tuberculosis himself and wrote of it in many of his books. This passage is from Roderick Random (I748), about a sick parade at sea: '... one (sailor) complained of a pleuritic stitch and spitting of 307
H. D. chalke blood for which the doctor prescribed exercises at the pump to promote expec- oration. In less than half an hour he was suffocated with a deluge of blood. (When tuberculosis was rife, the early symptoms of lassitude and a dislike of work were often mistaken for indolence. Tuberculosis was long an occupational disease of seamen: an epidemic occurred in the fleet blockading Brest in 1809. Washington Irving writes about the pressed sailor who dragged his wasted body homeward to repose and die (England's Rural life and Christmas Customs) Unsatisfactory, overcrowded quarters, were conducive to contact infection, and when'a long sea voyage' was a popular therapeutic measure for the consump- tive, sources of infection were not lacking. Charles Kingsley(he had chest disease all his life, dying in 1875)shows how readily infection was spread in those days, when people like the ploughmans consumptive daughter slept in a stiffing lean-to together with members of her own family, her baby and a newly married couple(reast). Kingsley's publisher and friend was Daniel Macmillan (4o) who had to contend with the millstone of tuberculosis all his life. One more novel is selected. this time from france-La Dame aux Camelias by Dumas fils(184 8). It is based on the real-life story of Marie Duplessis, a kept woman, who had what she described as one of those diseases that never relent I shall not live as long as others, I have promised myself to live more quickly she died at twenty-three o Katherine Mansfield, in her letters, gives a realistic picture of her conflict with ailment which ended with a haemorrhage Tuberculosis Among writers Numerous literary celebrities were themselves tuberculous; others may be presumed to have been affected, but biography often hides the truth and before the days of bacteriology and radiology, diagnosis must have been in doubt very often. Here are some names The Brontes (29)(3o)(39); Jane Austen(41); Katherine Mansfield(35) Smollet(50); Mrs Henry Wood(73)she had spinal disease and wrote fio R. L. Stevenson(44); D. H. Lawrence(45);Ll. Powys(55); Sterne(5 a wheelchair. (In Channings Jenkins had a'Churchyard cough a sort of decline, my wife and brother died of the same thing sir )Kingsley(56) Orwell(46) And from abroad Edgar Allan Poe(4o); Thoreau(45); Whittier(85); Washington Irving(76); Chekov(44); Schiller(46); Balzac(52); Moliere(51) Prosper Merimee(67 Poets are prominent in the list and more of them died young than othe writers.Poets, unlike most other geniuses, do not need a long life to achieve immortality, a few lines may suffice. Those who had consumption seem to have written with a hectic urgency, as though knowing that their time was short; a certain melancholy, symptomatic of their illness, is not unusual. Descriptions of o8
H. D. Chalke blood for which the doctor prescribed exercises at the pump to promote expectoration. In less than half an hour he was suffocated with a deluge of blood.' (When tuberculosis was rife, the early symptoms of lassitude and a dislike of work were often mistaken for indolence.) Tuberculosis was long an occupational disease of seamen: an epidemic occurred in the fleet blockading Brest in I809. Washington Irving writes about the pressed sailor who dragged his wasted body homeward to repose and die (England's Rural Life and Christmas Customs). Unsatisfactory, overcrowded quarters, were conducive to contact infection, and when 'a long sea voyage' was a popular therapeutic measure for the consumptive, sources of infection were not lacking. Charles Kingsley (he had chest disease all his life, dying in 1875) shows how readily infection was spread in those days, when people like the ploughman's consumptive daughter slept in a stifling lean-to together with members of her own family, her baby and a newly married couple (Yeast). Kingsley's publisher and friend was Daniel Macmillan (40) who had to contend with the millstone of tuberculosis all his life. One more novel is selected, this time from France-La Dame aux Camelias by Dumas fils (1848). It is based on the real-life story of Marie Duplessis, a kept woman, who had what she described as 'one of those diseases that never relent. I shall not live as long as others, I have promised myself to live more quickly'; she died at twenty-three. Katherine Mansfield, in her letters, gives a realistic picture ofher conffict with an ailment which ended with a haemorrhage. Tuberculosis Among Writers Numerous literary celebrities were themselves tuberculous; others may be presumed to have been affected, but biography often hides the truth and before the days of bacteriology and radiology, diagnosis must have been in doubt very often. Here are some names: The Brontes (29) (30) (39); Jane Austen (4I); Katherine Mansfield (35); R. L. Stevenson (44); D. H. Lawrence (45); LI. Powys (55); Sterne (55); Smollet (50); Mrs. Henry Wood (73)-she had spinal disease and wrote from a wheelchair. (In Channings Jenkins had a 'Churchyard cough . . . a sort of decline, my wife and brother died of the same thing sir'.) Kingsley (56); Orwell (46). And from abroad: Edgar Allan Poe (40); Thoreau (45); Whittier (85); Washington Irving (76); Chekov (44); Schiller (46); Balzac (52); Moliere (5I); Prosper Merimee (67). Poets Poets are prominent in the list and more of them died young than other writers. Poets, unlike most other geniuses, do not need a long life to achieve immortality, a few lines may suffice. Those who had consumption seem to have written with a hectic urgency, as though knowing that their time was short; a certain melancholy, symptomatic of their illness, is not unusual. Descriptions of 308
The Impact of Tuberculosis on History, Literature and Art the decline, always clothed in poetic euphemism, are to be found in great th grows pale and spectre-thin and dies'(Keats); 'And melancholy marked him for her own... he gave to misery all he had,a tear(Gray) The list of English poets is headed by Lovelace (4o) who ' grew very melan choly, which brought him at length into a consumption,. His circumstances became so reduced that when he died in 1658 he was in rags and lived with eggars. Others, with dates of death, are Philips(32)I708; Hughes(42)1719; Gay(47)1732 Littleton(64)1773; Keats(24)182I; Shelley(3o)drowned 1822; Hood (45) 1845; Gray(23)186I; E. B. Browning (55)186r; Symonds(53)I893 Thompson(48)Igo7; Flecker(31)I915; W. E. Henley (54)Igo,, who was lame following the amputation of a tuberculous foot, was the prototype of Long John Silver, in his great friend R. L. Stevenson's Treasure Island. Dylan Thomas(39), the modern poetic genius, did not suffer from tuber- culosis, but, according to a biographer, he imagined he did; a belief which may have served as an excuse for his alcoholism Death is near in all his verses and he had an obsession that a poet should die young and "live in such a way as to risk his own destruction' These few names are of poets who, despite short lives, lasted long enough to become famous thanks sometimes to their ability to move to a more equable climate abroad; in others biographical details are obscure, but suggestive; many more must have died young and unknown Close contact in the home has always been the most potent means of passing on the infection, and many of the famous people under discussion were members of tuberculous households, among them the brontes, Keats, Baillie, Hood Smollet, Chekhov, Trudeau. De Quincey, Rembrandt, John Hunter and others in this category seem to have escaped active disease. The home-life of th members of these families was disturbed by poverty, the loss of a parent, the despairing atmosphere of long drawn-out sickness and the fear that they them- selves might be similarly stricken. Tuberculosis, then, must be included among the causes of an unsatisfactory upbringing, leading to a feeling of insecurity, which is at the root of behaviour problems making their appearances later on Poverty was the usual accompaniment of early years in the literary and artistic fields and this and an unsettled way of life favoured a lowering of resistance at a time when none could avoid infection. Sometimes drugs and alcohol were super imposed on the toxins of the tubercle bacillus Edgar Allan Poe may be cited: he lost his father when he was a year old, his lingering illness when he was three and a half, his frail,ex quisitely tiful wife virginia, also tuberculous, died shortly after a marriage and squalor. She appears frequently in his poems te and nepenthe from the memories of Lenore. the wind came out of a cloud by night, chilling and killing my Annabel lee 3o9
The Impact of Tuberculosis on Histoy, Literature and Art the decline, always clothed in poetic euphemism, are to be found in great number: e.g. 'Where youth grows pale and spectre-thin and dies' (Keats); 'And melancholy marked him for her own ... he gave, to misery all he had, a tear' (Gray). The list of English poets is headed by Lovelace (40) who 'grew very melancholy, which brought him at length into a consumption'. His circumstances became so reduced that when he died in I658 he was in rags and lived with beggars. Others, with dates of death, are: Oldham (38) i688; Philips (32) I708; Hughes (42) I719; Gay (47) 1732; ? Littleton (64) I773; Keats (24) I821; Shelley (30) drowned I822; Hood (45) I845; Gray (23) i86i; E. B. Browning (55) i86i; Symonds (53) I893; Thompson (48) I907; Flecker (3I) 1915; W. E. Henley (54) 1903, who was lame following the amputation of a tuberculous foot, was the prototype of Long John Silver, in his great fiiend R. L. Stevenson's Treasure Island. Dylan Thomas (39), the modem poetic genius, did not suffer from tuberculosis, but, according to a biographer, he imagined he did; a beliefwhich may have served as an excuse for his alcoholism. Death is near in all his verses and he had an obsession that a poet should die young and 'live in such a way as to risk his own destruction'. These few names are of poets who, despite short lives, lasted long enough to become famous thanks sometimes to their ability to move to a more equable climate abroad; in others biographical details are obscure, but suggestive; many more must have died young and unknown. Close contact in the home has always been the most potent means of passing on the infection, and many ofthe famous people under discussion were members of tuberculous households, among them the Brontes, Keats, Baillie, Hood, Smollet, Chekhov, Trudeau. De Quincey, Rembrandt, John Hunter and others in this category seem to have escaped active disease. The home-life of the members of these families was disturbed by poverty, the loss of a parent, the despairing atmosphere of long drawn-out sickness and the fear that they themselves might be similarly stricken. Tuberculosis, then, must be included among the causes of an unsatisfactory upbringing, leading to a feeling of insecurity, which is at the root of behaviour problems making their appearances later on. Poverty was the usual accompaniment of early years in the literary and artistic fields and this and an unsettled way of life favoured a lowering of resistance at a time when none could avoid infection. Sometimes drugs and alcohol were superimposed on the toxins of the tubercle bacillus. Edgar Allan Poe may be cited: he lost his father when he was a year old, his mother after a lingering illness when he was three and a half, his frail, exquisitely beautiful wife Virginia, also tuberculous, died shortly after a marriage lived in penury and squalor. She appears frequently in his poems: .. . respite and nepenthe from the memories of Lenore. ... the wind came out of a cloud by night, chilling and killing my Annabel Lee. 309
h. d. chalke musician Purcell(37), who died in 1695, is the earliest English composer on the list; he caught a chill, said a biographer, after being kept outside his house by his wife as a punishment for keeping late hours! Many circumstances have been blamed for the onset of phthisis, but none as naive as this. Chopin(4o) is the classical type and his temperament is clearly reflected in his music. Nevin( 39), a lyrical genius who wrote The Rosary, struggled without avail against his ill-health. There are more names, including those of instrumentalists and singers. Mimi in La Boheme and Violetta in La Traviata are operatic consumptives Painters and paintings Relatively few artists app ear to have been afflicted (although many have died young before time was allowed them to achieve fame, their accelerated by the conditions under which they lived); there are at least notable exceptions Watteau(37), perhaps the greatest eighteenth-century painter, had an un- happy life. He was ill-fed and worked with feverish haste for long hours, painting exquisite romantic scenes which were in sharp contrast to the gloomy melancholy of his own life. He died in I72I. Modigliani(36), an original genius, who died 200 years after Watteau, lived imprudently and defiantly, sustaining himself with alcohol and drugs and sub- of young ladies with slender necks, slanting shoulders and peach blossom com plexions-Mlle Victoria, the English girl, was the model for many of them-is Aubrey Beardsley (27), was an unconventional black-and-white artist, the originator of a new cult. Seldom has anyone produced so much in such a short time, his friends attributing his abnormal activity to a desire to forestall death nd leave a legacy Portraiture supplements biography. There can be few galleries lacking a anvas or two showing a possibly tuberculous subject. The tuberculous type has long been recognized. Hippocrates wrote of those most liable, as having smooth, fair, ruddy skins, blue eyes and shoulders projecting like wings. The nineteenth century writers gave pictures of the same kind. One of the most colourful is in Lavengro(1851), believed to be George Borrows own biography; he describes his brother in these terms a rosy and light chestnut hair... it partook to a certain extent of ly in the fire and vitality which illumined it. So great was his beauty in infancy that rould follow... and bless the lovely face. Perhaps it will be asked here what became of him. Alas! his was an early and a foreign grave He became a painter, and was ' pale and unwell on his last visit to his home IO
H. D. Chalke Musicians Purcell (37), who died in I695, is the earliest English composer on the list; he caught a chill, said a biographer, after being kept outside his house by his wife as a punishment for keeping late hours! Many circumstances have been blamed for the onset of phthisis, but none as naive as this. Chopin (40) is the classical type and his temperament is clearly reflected in his music. Nevin (39), a lyrical genius who wrote The Rosary, struggled without avail against his ill-health. There are more names, including those of instrumentalists and singers. Mimi in La Boheme and Violetta in La Traviata are operatic consumptives. Painters and Paintings Relatively few artists appear to have been afflicted (although many must have died young before time was allowed them to achieve fame, their deaths accelerated by the conditions under which they lived); there are at least three notable exceptions: Watteau (37), perhaps the greatest eighteenth-century painter, had an unhappy life. He was ill-fed and worked with feverish haste for long hours, painting exquisite romantic scenes which were in sharp contrast to the gloomy melancholy of his own life. He died in I 72 1 . Modigliani (36), an original genius, who died 200 years after Watteau, lived imprudently and defiantly, sustaining himself with alcohol and drugs and subsisting on a diet which, it is said, consisted mainly of sardines. His portrayal of young ladies with slender necks, slanting shoulders and peach blossom complexions-Mlle Victoria, the English girl, was the model for many of them-is characteristic. Aubrey Beardsley (27), was an unconventional black-and-white artist, the originator of a new cult. Seldom has anyone produced so much in such a short time, his friends attributing his abnormal activity to a desire to forestall death and leave a legacy. Portraits Portraiture supplements biography. There can be few galleries lacking a canvas or two showing a possibly tuberculous subject. The tuberculous type has long been recognized. Hippocrates wrote of those most liable, as having smooth, fair, ruddy skins, blue eyes and shoulders projecting like wings. The nineteenthcentury writers gave pictures of the same kind. One of the most colourful is in Lavengro (I85i), believed to be George Borrow's own biography; he describes his brother in these terms: ... a rosy angelic face, blue eyes and light chestnut hair ... it partook to a certain extent of the Celtic character, particularly in the fire and vitality which illumined it. So great was his beauty in infancy that people would follow .. . and bless the lovely face. Perhaps it will be asked here what became of him. Alas! his was an early and a foreign grave. He became a painter, and was 'pale and unwell' on his last visit to his home. 310