Science, medicine, & societal changes
"Thus the ubiquitous presence of tuberculosis can be detected readily throughout the annals of the Western world in the nineteenth century."
  The White Plague  
Contents The Duboses' Themes Methods

Medicine as an incomplete arbiter of well-being based on a precarious balance of knowledge and neglect in the contested ground between health and disease in the case of tuberculosis.

descriptive versus empirical

disorder versus order

Chaos versus Cosmos

Customs versus fashions

"The epidemic became the White Plague, giving pallor to the dreariness of the mushrooming cities, and infecting its fever into the romantic moods of an age."

"...that tuberculosis is not, as Dickens believed, a disease that 'medicine never cured, wealth never warded off.' It is the consequence of gross defects in social organization, and of errors in individual behavior. Man can eradicate it without vaccines and without drugs by integrating biological wisdom into social technology, into the management of everyday life."

p. xxxvii

René and Jean Dubos

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

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

TB can effect

Functionality Breathing Speaking Eating
anatomical respiratory system throat digestive system
locus pulmonary, lungs

laryngeal, vocal chords

intestinal, bowels
symptoms congestion, loss of voice, diarrhea,


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

Affected area, organs disease
inflammation of the brain's membranes Meningeal TB
kidney tissue Renal TB
spine (curvature) Potts disease
skin Lupus
lungs Consumption, phthisis

p. 4

book 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 of all the Men of Death

Focus concern: how so many symptoms and divergent means of infection hampered diagnostic advances for what the Dubos' call "multiple personalities" that are characteristic of diseases. These numerous characteristics were so confusing that the recognition, diagnosis, and treatment of the disease was retarded.

p. 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."

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."


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.


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


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

Chapter 1: p. 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."


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."


A widely held bias and widespread authoritative belief that there were favorable and unfavorable conditions, environs, places with a milieu for advancing or preventing the advance of diseases.

Chapter 4: Contagion and Heredity

1546, Florentine physician Hyeronymus 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.


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


Heritable illness was seen as the weakness in the breeding lineage.

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.


Examples of familial consumption (TB):

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


"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..."


Chapter 5: Consumption and the Romantic Age.

"disease may also color the moods of civilizations."


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


Opera La Boheme, flower girl heroine dies of TB


Dickens in Nicolas 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,



"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."


outbreaks of TB or phthisis in the 1750-1950 period.

"The fir tree, alone in its vigor, green, stoical in the midst of this universal phthisis." Henri Amiel.


"The pervading presence of tuberculosis throughout society is reflected in all fields of literature."


"Like their contemporaries, they regarded tuberculosis as a refined disease in which the mind triumphs over the the body."


"look ugly" versus "the air of languor that is very becoming."

"Less explicit, but no less real, was the effect of phthisis on masculine manners. For instance it probably accounts for the frequent use of high neckwear by men."


"the attitude of perverted sentimentalism toward tuberculosis began to change in the last third of the nineteenth century."


"...became a blot on society, the symbol of all that was rotten in the industrial world."

With the coming of germ theory, the idea of tuberculosis associated with contagion became the manifestation of "something unclean."



Three historical stages in the development of understanding the disease of consumption


Ancient - Symptomatic-descriptive: phthisis

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


Renaissance - Anatamo-pathologic: consume

1640, Contagion theory advanced in Italy

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


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: Tubercle bacillus as biological agent, a "germ" or pathogenic bacteria
thriving under certain conditions of human habitation, touching, and hygiene

The White Plague
and poverty

Poor Laws 1700s
Industrial urbanization 1760s

quarantine & sanatoriums 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 Tuberculosis:

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


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


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. of upstate New York where he built a sanatorium for the ill.

He, sometime after 1865, 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


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

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

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


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


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


"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."


1761, percussion by Auenbrugger

1816, mediate ausculation with / a stethoscope by Laënnec



Chapter 7: Percussion, the Unitarian Theory

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


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



Chapter 8: The Germ Theory

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


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


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



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 microorganisms."



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

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 Sanatoria

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



"Thomas Young


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

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


long before the microbiological discovery of TB [tubercle bacillus] bacteria, the rate of morbidity & mortality was falling, even before the anti tubercular campaign.


"end of a natural epidemic wave"




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


"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."


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


"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."


"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."


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




medical science …confirmed the value of certain ancient practices.


"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