| 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 | ||
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| 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
The White
Plague: Tuberculosis, Man, and Society (1952)
Overview | Part One: | Part Two: | Part Three: | Part Four: | Summary | Lessons
| 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
Part One: The Nineteenth
Century
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."
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."
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."
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
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.
28-29
1650, The Faculty of the University of Paris Medical School doubted the Italian theory of contagion.
33
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.
33
Examples of familial consumption (TB):
- Bronté 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 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,
59
"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 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.
46.
"The pervading presence of tuberculosis throughout society is reflected in all fields of literature."
47.
"Like their contemporaries, they regarded tuberculosis as a refined disease in which the mind triumphs over the the body."
53.
"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."
58.
"the attitude of perverted sentimentalism toward tuberculosis began to change in the last third of the nineteenth century."
65.
"...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."
66.
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 - phlegmaticRenaissance - 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 1760squarantine & sanatoriums 1790s
Public Health movement 1830s (UK), 1850s-1890s (America)
Social Darwinism 1859-1995
war and diseaseCrimea, 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:
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 techniquessound 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
"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
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 ausculation with / 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
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 microorganisms."
111
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.
132
"Thomas Young
131
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
185
long before the microbiological discovery of TB [tubercle bacillus] bacteria, the rate of morbidity & mortality was falling, even before the anti tubercular campaign.
186
"end of a natural epidemic wave"
187
Overview | Part One: | Part Two: | Part Three: | Part Four: | Summary | Lessons
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."
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."
"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
Overview | Part One: | Part Two: | Part Three: | Part Four: | Summary | Lessons
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
