Science

order versus disorder

Medicine as an enduring arbiter of health and disease

Notes on the entire book | Themes of the book in perspective | MLS context | Scientific methods of later medical studies | Authors & photographs

René and Jean Dubos

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

Contents

Introduction

"The medical & social conception of tuberculosis . . . explored in three sections"

1)    "The first concerns a shift in attention away from the sick person and [to] the presumption that everyone was susceptible to this common disease."

2)    "The second considers . . . declining rates of death and disease from tuberculosis. . . . "

3)    "The third examines some of the concerns about tuberculosis that surfaced after the introduction of antibiotics . . . "

pp. viii-xiv.

3)    "The scientific perspective shapes the Duboses' history of tuberculosis. In the twentieth century, medical researchers drew lessons from their observations of the reciprocity between parasite and host. . . . 'to make sense' of nature, . . . . "

p. xxiii.

Overview

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.

Chapter One: The Captain...

multiple personalities are characteristic of diseases also

3

"the fact that succeeding ages have looked at tuberculosis from various points of view , emphasizing the different aspects of it. The never-ending metamorphosis of words is the method by which language adapts itself to the impact of new discoveries, and to changes in attitude concerning the nature of disease and its effect on man."

TB can effect

Tubercle bacilli can reside anywhere in the body, as the appearance of generalized nodules in a variety of organs and lymph tissue, or TB can manifest locally:

Other TB effects

p. 4

Chapter 1:

TBs "signs are described frequently and at length by Hindu, Greek, and Roman writers, who lived in urban societies, but they are barely mentioned in the Bible and the lore of pastoral peoples."

6

Pulmonary consumption was recognized in the earliest English hospitals in the 1650s --causing one death in five-- and peaked in 1780s to 1850s in England and the Americas.

8

Maybe as high as half the English population of the 1840s

9

1824, The Lancet noted the number of young West Indian boys the majority of whom become "scrofulous."

10

Chapter 2: Death Warrant for Keats (& morbidity for Shelley)

"the perverted attitude of the romantic era toward the disease and the ignorance of ... medicine concerning its diagnosis, nature and treatment."

11

Chapter 3: Flight from the North Winds

"Keats and Shelley symbolize the romantic and consumptive youths....They were part of a great pilgrimage...leading the sick...toward the Southern sun."

19

Chapter 4: Contagion and Heredity

1546, Florentine physician Hyeronymous Fracastorius, advanced the contagion theory: communication by exposure to air, breath or fluids of consumptive patients.

1699 Spain and Italian city states passed regulations to control the unnecessary spread of consumption.

28-29

1650, The Faculty of U. of Paris Medical School doubted the Italian theory of contagion.

33

Phthisiologia by Richard Morgan, in 1688, described the inherited condition to account for the spread of consumption as opposed to "contagion."

Louis 13th and Louis 14th were consumptives, the former died of it as did the Queen.

33

Examples of familial TB:

Brontë family

Ralph Waldo Emerson family

Thoreau family

"the disease was the outcome of a bad hereditary constitution"

42

"born with a predisposition to phthisis"

"only balmy air and sunny skies, it was thought, could arrest the destruction of lung tissue and the sapping of strength that otherwise drove the consumptive to certain death..."

43

Chapter 5: Consumption and the Romantic Age.

"disease may also color the moods of civilizations."

44

Common in the literature of romantic writers for characters to die of consumption

47

Opera La Boheme, flower girl heroine dies of TB

50

Dickens in Nicholas Nickleby describes TB as the agent that rarifies the body to take the spirit form

some relation between TB and genius, expressed by Alexander Dumas,

59

Overview

"The health of nations"

from Tuberculosis to Influenza: 1710 - 1919

"Epidemics have often been more influential than statesmen and soldiers in shaping the course of political history."

44

outbreaks of TB

Stages in the development of understanding the disease of consumption

EO

Ancient - Symptomatic-descriptive: phthisis

1000 BC evidence in bones of Egyptian mummies of TB
400 BC. De Morbis, Hippocrates -phlegmatic

MEZZO

Renaissance - Anatamo-pathologic: consume

1640, Contagion theory advanced in Italy

1650, Parisian Faculty propose the familial, hereditary agent in phthisis
1679, Franciscus Sylvius; "tubercles"

NEO

Modern - Germ theory - tuberculosis

1722, Benjamin Marten "animalculae … gnawing

1840s the first appearance of the term "tubercles" as an anatomical designation
1865, Jean Antoine Villemin, Etudes sur
3/24/1882, Robert Koch: T. bacillus as biological agent, a "germ" or pathogenic bacteria

The White Plague and poverty

Poor Laws 1700s
Industrial urbanization 1760s

quarantine & sanitoriums 1790s

Public Health movement 1830s (UK), 1850s-1890s (America)

Social Darwinism 1859-1995

war and disease

Crimea, 1850
S. Africa, 1898
Europe, 1914
India, 1920

By 1900 "tuberculosis remained the greatest killer of the human race…" (186)

"The passion for financial gains made acquisitive men blind to the fact that they were part of the same social body as the unfortunates who operated their machines. TB was, in effect, the social disease of the 19th century, perhaps the first penalty that capitalistic society had to pay for the ruthless exploitation of labor." (207)

Manchester Board of Health, 1796

Report of an appointed commission to the Board

"Children and others who work in large cotton factories are particularly disposed to be affected by the contagion of fever, and when such infection is received, it is rapidly propagated, not only amongst those who are crowded together in the same departments, but in the families and neighborhoods to which they belong."

"To him who follows her way, Nature reveals many roads that lead in the direction of truth."

Three phases of understanding TB:

1. Descriptive diagnostics
   
2. Anatomo-Pathology diagnostics
   
3. Diagnostic - Germ Theory & inoculation diagnostics Descriptive
   

There is a persistent difficulty of any degree of certainty in curing TB, even in the modern period/

In the absence of physiological data; error abounds.

Descriptive diagnostics

Hippocratic corpus, 400 BCE

malaise -- a symptom of many diseases; listless
phthisis --wasting of the body due to lung infection
catarrh -- chest pain, progressing to the excessive production of yellow sputum

Anatomo-Pathologic

lymph nodules infected -- tubercles (1679) of diverse shape, appearance, location in lungs, stomach, bowels.
1650, Fernal; 1679, 1700, Manget; 1790, Baille
insufficiency of descriptive science in health studies

Integration of pathological & clinical techniques

sound of the lungs -- percussion 1761
stethoscope for auscultation in 1816
microscope -- 1590 first invented; TB in 1840s

René Théophile Hyacinthe Laënnec; 1781-1826

"Laënnec gave precise and original descriptions of clinical symptoms and post-mortem appearances of pulmonary tuberculosis, pneumonia,… " based on the description of heart and chest sounds (87)

within 10 years of 1819 the technique of "mediate auscultation" with a stethoscope was widely practiced.
92) necessity of experimental proof

Diagnostic (germ Theory)

"hundreds of sanatoria sprang up along all the European shores." well respected by 1882

Edward Livingston Trudeau brought the idea to America at Saranac Lake in the Adirondack Mts.
sometime after 1865 he contracted TB.

"fond of hunting and of life in the wilderness."
"a longing I had for rest & peace in the great wilderness."

" a rough inaccessible region" (179)

"Tuberculosis has waxed and waned several times in the course of human history."

"A peculiar fact emerges…,that TB began to decrease long before any specific measures had been instituted against the disease - before there was any scientific basis on which to formulate antituberculosis campaigns." (185-86)

Overview | Part One: | Part Two: | Part Three: | Part Four: | Summary | Lessons

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

Chapter 6: Phthisis, Consumption, Tubercles

1881, Medical Practitioner's argued the non-contagious quality of TB

1882, Koch identified the growth of bacteria as the cause of TB

69

"damage caused by bacilli multiplying in the infected tissues."

"a confusing array of signs and symptoms...as the expression of different maladies."

"an orderly system based purely on clinical and pathological criteria," before the 1882 discovery

70

phthoe Greek term for shriveling under high heat, temperature, wasting away, root of phthisis.

71

"every system of classification suggested a new theory of the nature of pulmonary phthisis."

74

"This anatomical knowledge served as a basis for the formulation of hypotheses concerning the evolution of each disease from its early phase to its ultimate manifestation."

76

1761, percussion by Auenbrugger

1816, mediate auscultation w/ a stethoscope by Laënnec

76

Chapter 7: Percussion, the Unitarian Theory

1761, percussion was used by Auenbrugger to listen to the sound of the chest by listening.

77

Laënnec could not prove his theory" "the unitary theory of phthisis"

92

Chapter 8: The Germ Theory

1722, Benjamin Marten, first proposed a microbe "gnawing away" as the cause of TB instead of contagion

94

Double blind experiments, where the agent induces the disease in lab animals.

101-103

Bovine forms of TB, transported in unpasteurized milk were a principle suspect in the origins of the disease.

109-110

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 produce a new generation approximately twice a day, twenty times slower than most other microrganisms."

111

 

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

Thomas Young, recovered TB victim and physician, in 1815 published recommending measuring pulmonary capacity.

132

"Thomas Young

131

Part Four: TB and Society

Chapter 14: The evolution of Epidemics

Chapter 15: Industrial civilization

Chapter 16: Social Technology

Chapter 14: The evolution of Epidemics

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

morbidity rates

185

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

186

"end of a natural epidemic wave"

187

Summary

"Admittedly the medical techniques used in the management of the tuberculosis patient, whether carried out in a city hospital of in a secluded country sanatorium, are of benefit to both patient and society. But it is probable that equally good therapeutic results would be obtained with more certainty, less time, and at lower cost of human and economic values, if knowledge were available of the factors that affect the course of tuberculosis."

226

But the complete control of tuberculosis in society goes beyond medicine in its limited sense. It is a problem in social technology,."

227

"Once more it becomes urgent to force upon social consciousness the realization that progress does not consist merely in doing more and more of what proved profitable in the past."

227

"This is true of the infections caused by tubercle bacilli which, however widespread, are always less destructive in societies that live and function according to physiological common sense."

"The final step in the conquest of tuberculosis may well depend upon knowledge of the factors that prevent silent infection from manifesting itself in the form of overt disease."

228

Lessons:

medical science …confirmed the value of certain ancient practices.

228

"the art of achieving fitness between human urges and the natural environment." "many primitive civilizations have achieved" this.

There remains a need to

"incorporate physiological principles in the complex fabric of industrial society."

Overview | Part One: | Part Two: | Part Three: | Part Four: | Summary | Lessons