book Book Notes

The White Plague, Tuberculosis, Man, and Society. (1952)


Part One: The Nineteenth Century.
Part Two: The Causes of Tuberculosis.
Part Three: Cure and Prevention of TB.
Part Four: Tuberculosis and Society.


Part One: The Nineteenth Century

            Chapter 1: The Captain...

            Chapter 2: Death Warrant for Keats

            Chapter 3: Flight from the North Winds

            Chapter 4: Contagion and Heredity

            Chapter 5: Consumption and the Romantic Age.


Part Two: The Causes of Tuberculosis

            Chapter 6: Phthisis, Consumption, Tubercles

            Chapter 7: Percussion, the Unitarian Theory

            Chapter 8: The Germ Theory

            Chapter 9: Infection and Disease


Part Three: Cure and Prevention of TB

            Chapter 10: Evaluating Therapeutic Procedures

            Chapter 11: Treatment and Natural Resistance

            Chapter 12: Drugs, Vaccines and Public Health

            Chapter 13: Healthy Living and Sanitoria


Part Four: TB and Society

            Chapter 14: The evolution of Epidemics

            Chapter 15: Industrial civilization

            Chapter 16: Social Technology




Jean & René Dubos

Combined and epidemiological/ecological approach

"tuberculosis was a widespread and deadly infectious disease. . . . the source of a staggering amount of illness and mortality and engaged some of the best minds in the medical sciences."

"Developed a respect for the mystery of this disease."

As both

1.A methodological improvement in the understanding of health,”

2.the basis of a humanistic philosophy that could help preserve the best qualities of mankind through the awareness of the complex interrelationships between populations and environments.”


"René Dubos was a pioneer who introduced many of us to the marvels and significance of these transactions between man [humans] and environment and the extraordinary adaptiveness of organisms to changing conditions. However, as he knew, the human capacity to reconstruct the environment symbolically and to manipulate it physically opened new but sometime threatening avenues."

David Mechanic, pp. vii-xi.





disease was a prevalent and destructive experience that threatened social order....Human history and tubercle bacillus are so enmeshed  that to follow the course of the disease over time is a prerequisite to understanding what the whole struggle to control disease means to ourselves and our contemporary society.”


reflections about the medical and social conception of tuberculosis.”

Consumptive personal ą microbe specific, disease causing agent (1882)­ąsocial hygiene/public health stages with the introduction of first therapy and second antibiotic treatment phases.


“Tuberculosis, however, was already a less ominous disease for the audience that read The White Plague when it was first published in 1952.


100,00 case per annum of which declined from 34,000 to 11,000 annually.


Jean and René Dubos called tuberculosis ‘a social disease’ in order to associate the disease with poverty, although the term was more commonly associated with sexually transmitted diseases.”


“Economic and social conditions, the Duboses stressed, were crucial factors in its transmission.”

“. . . had profound social consequences in that it affected the ‘emotional and intellectual climate of the societies it attacked’.”


it is emphatically a disease of the 19th century.”            Industrialism and pollution


“Alongside their account of the social ecology of tuberculosis, the Duboses celebrate the history of scientific research that culminated in Robert Koch’s discovery of the tubercle bacillus in 1882.”


“It was at last possible to show the common pathology of different symptoms and the necessary bacterial origin of every tubercular infection.”


“...first examining the complex social environment that generated the conditions of disease, and the second celebrating the growth of scientific knowledge about the biology of tuberculosis, added an important tension to the Duboses’ narrative. . . .”

Resistence to infection was the best explanation for this fall in the death rates.”


“On the other hand, the discovery of tubercle bacillus and the demonstration of its necessary role in disease failed, at first, to change the minds of many doctors and the public, who continued to blame the incidence of tuberculosis on heredity, climate, or psychogenic causes.”


“Evidence that pathogenic organisms, including tubercle bacillus, developed drug resistant strains underscored the potential for medical disaster and the need for therapeutic prudence.”


Nature reveals many roads that lead to the direction of truth.” René & Jean Dubose in their own words


transform the human experience of illness.”


“They perceived a danger in the scientific and social logic that aimed to treat the disease rather than to modify the underlying causes of vulnerability, and their own moral logic served to inform their history of tuberculosis.”




Chapter 1:The Captain

Chapter 2: Death Warrant for Keats

Chapter 3: Flight from the North Winds


Keats and Shelley, (Paganini, Tsarevitch Nicolas, and famous families Bronte’s, Trolopes)

“They were part of a great pilgrimage, begun long before, leading the sick from the Northern fog toward the Southern sun–shrine of health joy and illusion.”



the Mediterranean coast as ‘the last ditch of the consumptive’.”


“But for most Americans, the Southern and Western states were less forbidding than Europe. Florida and the Caribbean Islands, and later Colorado, New Mexico, and Arizona, provided for North American consumptives the illusion of refuge with which the Mediterranean lured their European brothers in disease.”


Cecil Rhodes went to Natal for the cure from Oxford.


Cicero – cured or health improved considerably by sea voyages


Chapter 4: Contagion and Heredity


Southern European doctors believed in contagion –exposure

Northern European doctors believed in heredity, a predisposition due to inheritance (families)


Chapter 5:  Consumption and the Romantic Age


Epidemics have often been more influential than statesmen and soldiers in shaping the course of political history, and diseases may also color the moods of civilians. Because they are part of everyday life, . . their role is rarely emphasized by historians.”


“Tuberculosis then being so prevalent, may have contributed to the atmosphere of gloom that made possible the success of the ‘graveyard school’ of poetry and the development of the romantic mood.”

p. 44.

“. . .became popular themes over much of Europe around 1750. . . . “



Chapter 6: Phthisis, Consumption and Tubercles


In 1881 August Flint published in collaboration with William H. Welch – The Principles and Practices of Medicine.


“The authors dealt at length with the subject of tuberculosis, mentioning as its causes: hereditary disposition, unfavorable climate, sedentary indoor life, defective ventilation, deficiency of light and ‘depressing emotions’.”

contagiousness. . . has its advocates, but the general belief  is in its non-communicability.”


become so soon and completely  outmoded,”    


1882 Robert Koch’s discovery of the causative agent, tubercle bacilli, established for a time the dominance of the germ theory of disease over the competing hereditary versus environmental theories and brings ecological health to the forefront of scientific thinking.

p. 69

Chapter 7: Percussion, Auscultation and the Unitarian Theory of Phthisis


in 1761, a new method for the detection of diseases of the chest.  The method was based on the observation of the thorax, on being tapped, yields” different sounds.


LaĎnnec in 1803 “found tubercles in all organs of the body, muscle and bone included.”

p. 83.

were in reality, all different phases in the evolution of the same pathological process.”

pp. 83-84.

Chapter 8:       The Germ Theory of Tuberculosis


“The belief in the contagiousness of phthisis first became firmly entrenched, . .  .in Italy, Spain, and the South of France.

Benjamin Marten, in a volume printed in London, in 1722 he presented his opinion that animalculae’. . . were the immediate cause of the disease.”

p. 94




Chapter 9: Infection and Disease


Tubercle bacilli are minute rods, so small that large numbers of them can be packed inside the microscopic white cells of the blood and tissues.” “. . . they are readily engulfed by these white cells, in health as well as in disease.”

p. 111.

“Thus, certain fractions of the dead bacilli elicit the production of characteristic tubercles, whereas others render the animals allergic to tuberculin; injection in large amounts of bacillary material can cause the appearance of ulcers full of caseous* material, and even bring about a state of chronic toxemia, with progressive emaciation resulting in death.”

p. 112.

“Fortunately most of the bacilli with which we come in contact are not capable of multiplying extensively in our tissues.”

p. 113.


Chapter 10: The evaluation of Therapeutic Procedures


Like many of his contemporaries, the famous English scientist, Thomas Young, had suffered from consumption during his early adulthood. . . he had made a full recovery.”


he recommended early diagnosis” and intervention –advocated spirometry


“He discussed the occurrence of consumption in different parts of the world and in different populations and presented some evidence suggesting it infectious nature.”

p. 131.


Chapter 11: Treatment and Natural Resistance


As long as tuberculosis was diagnosed only in its late phase, the relief of distressing symptoms occupied the most important place in treatment.”


“ . . .they improved the sense of well-being of the patient. To this class belongs the inhalation of vapors from resinous, balsamic substances and emollient herbs, the sucking of cracked ice in hemoptysis**, the use of opiates for quieting cough and the pains of intestinal tuberculosis.”


Pierre Louis “He thus convinced himself that none of the drugs then known were of benefit in tuberculosis. But of opium he said, ‘It frequently produces so material an improvement in chronic phthisis, that the patients fancy themselves cured, or almost cured, after having taken a few doses’.”

p. 139.

Cod liver oil                                                                                                    p. 140.


Chapter 12:  Drugs, Vaccines and Public Health Measures


“The Germ Theory opened several new lines of attack against tuberculosis. It stimulated the search for antimicrobial drugs useful in treatment, and for vaccines capable of immunizing the well person against infection. It led to the development of techniques for the detection of infected individuals and to sanitary measures for preventing the spread of disease.”


“ . . . unforeseen and formidable obstacles have been encountered on the way.”

p. 154.

“The first convincing reports of therapeutic effect in tuberculosis of the guinea pig were published in the 1930s­–first with sulfanimide and then with diamino-diphenyl-sulfone. Although these two drugs proved useless in the treatment of human tuberculosis, the demonstration of their effectiveness in animals acted as a great stimulus for further research and soon led to the discovery of several substances, which can be used in man. Of these, streptomycin and para-amino-salicylic acid (PAS) appear, to date, the most useful; they exhibit an immense activity against tubercle bacilli.”

p. 154-55.

patients suffering from miliary and meningeal tuberculosis” ... “almost invariably fatal before the use of the drug (streptomycin).”


Chapter 13: Healthy Living and Sanitoria


The knowledge and traditions concerning the management of the tuberculous patient are now codified in the formula of sanatorium life.”


“. . .but these are all hospitals and not places devoted primarily to a healthy way of life.”


1791, by Lettsom, a fashionable Quaker physician in London


“And for a few decades longer the medical profession continued to regard abundant food and fresh air as poisons for the tuberculous patient.”


the sanitary revolution”

“In 1853, for example, the Government of Lucca in Italy began sending scrofulous children to the sea baths at Viareggio.”


“The work of the German Hermann Brehner marked the turning point in the treatment of tuberculosis throughout the world.”


Born in Silesia in 1826, 1853


doctoral dissertation  to the theme that pulmonary tuberculosis  is curable.”


his belief at in the beneficial effects of life at high altitudes . . . Alexander von Humboldt who had assured him that the disease did not exist in mountainous areas.”


Edward Livingston Trudeau

Chapter 14: The evolution of Epidemics

1650 and 1850 the high mortality periods for TB in Britain & Europe.


400 in 1835     for Boston, New York, and Philadelphia

  26 in 1950

morbidity rates deaths per one hundred thousand


“That tuberculosis began to decrease long before any special measures had been instituted against the disease–indeed, before there was any scientific basis on which to formulate anti-tuberculosis campaigns.”


long before the microbiological discovery of TB bacteria, the rate of morbidity & mortality was falling, even before the antitubercular campaign.


the treatment and segregation of patients in sanatoria did not gain momentum until 1900; vaccination is only now (1950s) coming into use and is not practiced at all in some of the places where mortality has reached its lowest level, as to therapeutic measures–like lung collapse, thoracic surgery, and the use of streptomycin and PAS–they are of too recent date to have played a part in the phenomenon.”


“But even at this lower level (200/100,000) tuberculosis remained the greatest killer of the human race, and it is not surprising, therefore, that many physicians and public health officers remained for a time unaware of the downward trend that had begun spontaneously.”


“TB is not the only infectious disease that exhibits an apparently spontaneous ebb and flow. Most epidemics first appear in the form of a few sporadic cases; this is the early phase followed by one of great prevalence and severity; then new cases become progressively fewer and fewer, the disease often taking a benign character before disappearing almost completely for a time.”


there are on record, for example, many outbreaks of epidemic influenza recurring at intervals of apparently twenty years: but it is probable that the profound changes in the distribution of populations and in medical practices during the past few decades will blur considerably, or even eliminate completely, the regularity of this epidemic cycle.”


“Tests in experimental animals have so far failed to give any indication that the virulence of tuberculosis has significantly decreased during historical times, or at least since the bacteriological era.”


“However, it is much more difficult to demonstrate the role of inherited susceptibility and resistance in the general population, partly because genetic traits are distributed in such a complex manner that they fail to appear as a clear pattern, partly because the influence of environmental factors on the course of tuberculosis is so great as to mask the manifestations of hereditary characteristics.”

“...most of the susceptible die young without leaving any progeny.” { evolution unaffected

[hence chances of  inherited disease proclivity is decreased]


“Selective elimination of the most susceptible”

there is evidence that repeated  exposure to infection confers on survivors an acquired immunity which supplements their innate endowments”


they become allergic to tuberculin  without ever showing any evidence of clinical disease.”


“Exposure in childhood, over time  “may have led progressively to the development in urbanized areas of a partially immune population.”

tuberculosis  usually exhibits  a very acute course in populations newly exposed to it.”


9000 / 100,000 Indians in western Canada were infected with TB once they abandoned their hunting way of life and settled down into sedentary villages.


40% of the deaths in Hawaii and New Caledonia, after contact, were attributed to TB.


“European people of Celtic origin appear to be particularly susceptible to TB.”


“The history of TB in different human populations makes it plain that racial (ethnic) susceptibility or resistance is to a very large extent a consequence of social history.”

Rural nomadic people become susceptible to virulent TB

• Urban exposed populations become resistant to TB


“…it is also true that living conditions are (diet?)  of paramount importance in determining the severity of this response.”

From 83 / 100,000 [Manhattan] to  52/100,000  [Bronx] among  densely settled and less densely settle Jewish communities in NYC .


wretched economic status” can mask the otherwise decline in cases among less dense populations.

TB in Paris shot up during the siege of the Franco-Prussian War, 1871


“Thus the course of TB during and after the war illustrates in  a striking manner the powers at the disposal of the human body  to master the disease when living conditions are favorable.”


“It seems that the severity of TB immediately reflect the complex of disturbances brought about in the community as a whole by most forms of social upheavals, be they abrupt changes in ancestral habits, rapid industrialization, or wars.”


“Obviously the equilibrium between man and the tubercle bacillus is very precarious.”



Chapter 15: Industrial civilization


Each and every vice, large or small–in fact almost any form of unconventional behavior–was regarded as a cause of consumption during the nineteenth century. According to their personal prejudices, reformers and physicians traced the disease to immoderate love of food, spirits, or social life; to newfangled fashions, venery, or lack of exercise, to excessive use of tobacco or a passion for dancing.”


impure air, drunkenness,  and want among the poor, and by dissipation and enervating luxuries among the rich.”

p. 197.

Chapter 16: Social Technology


The sufferings and loss of human values caused by the industrial revolution were unnoticed at first by most of those who enjoyed the fruits of the new prosperity. But soon,  the horrors of the manufacturing cities began to prey on the social conscience, and protests arose in every land.”


“Robert Owen proved by organizing model factories that humane standards of work in industry were not incompatible with financial success.”


1837 Chadwick – Sanitary Commission published in 1842 in UK ”fought for fair labor laws.”


sweated labor  of tuberculous tailors”


“By 1850 reformers had come into action everywhere, attacking the social problems by political action, or devoting their efforts to improving the physical environment in which men had to live and function.”

pp. 208-209.

Further notes:







a form of necrosis characteristic of tuberculosis, in which diseased tissue forms a firm, dry mass like cheese in appearance.



coughing up blood.