The Captain of the Men of Death

Yet the captain of all these men of death that came against him to take him away, was the consumption, for it was that that brought him down to the grave.

—John Bunyan

Today, 24 March is World Tuberculosis Day (and here) and the anniversary of the day in 1882 when Robert Koch announced his finding of Mycobacterium tuberculosis as the causative germ of TB.

TB, in those days was a major cause of death, accounting for perhaps 20% of all deaths. Until Koch’s announcement, and the development of the germ theory of disease, the exact cause was unknown; some even thought it might be an inherited disease.

In Koch’s day there was no effective treatment for a disease, though certainly associated with poverty and malnutrition, could strike all classes. Symptoms typically are a persisting fever, weight loss and a productive cough; the sufferer may cough up blood. It often caused anaemia, hence it’s name as ‘The White Death’. Expectorated sputum harboured viable germs, which could survive for long periods; it’s why ‘No Spitting’ notices were prominent on public transport.

Various treatments, if they can be called that, were tried. Nutritious food, complete, enforced rest and mountain air certainly seemed to help. Yet it’s uncertain how much good they did, for some people did seem to recover spontaneously. Davos, in Switzerland, was the first clinic and sanatorium offering fresh mountain air; Davos had a reputation for being largely free of TB. Whether this was the natural constitution of the Swiss is unknown. As TB needs a lot of oxygen to live and reproduce, it might be argued that high altitudes, where the air is ‘thinner’, would be helpful; but this seems specious.

A number of surgical treatments were tried, largely based on the idea of ‘rest’. The muscle of the diaphragm could be paralysed and an artificial pneumothorax (air in the chest cavity, collapsing the lung) could be maintained with a special machine. In severe cases, multiple ribs could be removed, again collapsing that part of the lung.

It was only the discovery of the antibiotic streptomycin in the late 1940s, followed by isoniazid a few years later, that any real, effective and curative therapy was possible. These two were followed by rifampicin about 20 years later.

It looked as if the curse of TB would be soon over. However, inappropriate and inadequate courses of antibiotics lead to the development of antibiotic resistance. Today, there are strains which are ‘multi-resistant’ to antibiotics.

A related illness is bovine TB, found in cows and badgers, and caused by M bovis. Humans who drink raw, unpasteurised milk can contract a form of TB, but in the belly rather than in the lungs. (When I was very young, I had a persisting fever, a ‘PUO’, and was off school for a complete term. I spent a week in the Ava hospital, where I had a chest x-ray, and they attempted without success to get a specimen of sputum off me. I didn’t get any specific treatment, apparently recovering spontaneously. Clearly, it was thought that I had TB. Many years later, an x-ray showed a calcified abdominal lymph gland. These are quite common in us seniors, and are pathognomonic of TB. I then remembered drinking warm, raw milk from a cow on a farm where we spent several holidays.)

Though developed early in the 20th century, BCG (Bacille Calmette-Guérin, an attenuated form of M Bovis) it wasn’t until after WWII that it was widely introduced. As a vaccine it afford some, though not complete, protection.

Sadly, the resurgence in the incidence of TB continues. It’s reported that in N Ireland, there has been a rise of nearly a third in the number of cases.

TB played a large role in the popular imagination and in fiction. A sanatorium at Davos was the setting of Thomas Mann’s novel, The Magic Mountain. In opera, it was the heroine, a young beauty who succumbed; think of Mimi in Puccini’s La Bohème, dying in the Parisian garret; or of Violetta in Verdi’s La Traviata (The Fallen Woman). Violetta was based on La Dame aux Camélias by Alexandre Dumas fils. And Dumas got his inspiration from his passion, shared with Franz Lizst, for the very real Marie Duplessis, (and here) who died just after her 23^rd birthday.

Robert Campbell

Robert Campbell is a retired surgeon.