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