Tuberculosis in time

The white death: a history of tuberculosis Thomas Dormandy New York University, New York; 2000 433 pp. US$29.95 (cloth) ISBN 0-8147-1927-9

Edward Trudeau, the American physician who through personal experience stumbled upon the ”rest cure” for tuberculosis, once observed that the causative organism of the disease ”bore cheerfully a degree of medication which proved fatal to its host.” A plague since the days of ancient Egypt, tuberculosis has taken millions of lives over the centuries, and it was not until a mere half-century ago that a cure seemed possible. Before that, some physicians prescribed sensible regimens based on fresh air, plain diet and moderate exercise, but all too many recommended nostrums that were valueless, ranging from the frankly harmful, such as antimony, to the innocuous but inefficacious, like calcium and heliotherapy. Quacks lauded bottled mysteries such as Bumfritt‚s Incomparable Sputum Softener and even Austrian alpine air. Meanwhile, a majority of the tuberculous continued to die of their disease. Not until the advent of streptomycin and para-aminosalicylic acid in the 1940s, followed by isoniazid in the 1950s, did the future for these patients begin to look bright, and by the 1970s it seemed that the struggle might have been won.

But tuberculosis is still a deadly disease. As Thomas Dormandy points out in The White Plague: A History of Tuberculosis, outbreaks with a mortality approaching 90% have occurred as recently as 1991 — not in a developing country, but in New York City. Events such as these must give us pause. Dormandy takes a pessimistic view of the future, raising the possibility of ”a global wave of virtually incurable tuberculosis” arising from two recent developments: opportunistic infection in HIV-positive individuals and the rise of multiple drug resistance. ”The prospect,” he warns, ”is not a pleasant one.”

It is instructive to read a current history of tuberculosis, now that AIDS has replaced it as our chief concern, to some extent in North America but particularly in Africa and Asia. Formerly, tuberculosis was the chief killer of young people in the western world; now, AIDS is ravaging Africa. As Dormandy shows, much nonsense was written about tuberculosis; today, some of what is said about AIDS is illogical. He reminds us that it took centuries, and much work by many physicians and scientists, to develop a vaccine and then efficacious treatment for tuberculosis, and it is to be hoped that today‚s accelerated pace of discovery will mean that it will take less time for a vaccine and accessible therapy for AIDS to be developed. But in many respects the story of tuberculosis must make us wary when we ponder not only tuberculosis as a continuing threat but also AIDS.

Sir George Pickering once said that the history of medicine was a monument to human folly, and much of what Dormandy has to say about the way tuberculosis was treated bears this out. Consider some of the regimens that have been advocated: the King‚s touch for scrofula (”a malady,” said Ambrose Bierce, ”that was formerly cured by the touch of a sovereign, but now has to be treated by the physicians”); the breathing of warm animals‚ expired air; the administration of pig-spleen extract; the pumping of air superheated to 150∘ into the rectum; and l‚eau antipulmonaire du Docteur Marat, which proved to be no more than dilute calcium phosphate. All these and many besides were reported by reputable physicians to give good results, despite, or because of, the absence of controlled trials. At the same time, Dormandy lauds the work of those physicians and scientists who built up the knowledge that led to our understanding of the cause, diagnosis and treatment of tuberculosis. So he provides informative accounts of Auenbrugger, Corvisart, Laennec, Budd, Bodington, Villemin and Koch. In these respects his knowledge of the history of medicine serves as a broad base for his history of tuberculosis.

That being said, Dormandy is at least as interested in the perceived effects of this scourge on great cultural figures of the 19th century as he is in the scientific aspects of the disease. He has an encyclopedic knowledge of the many artists, musicians and writers who died from tuberculosis, and for the most part his accounts of their short lives have undeniable interest. But the very multiplicity of these biographies — of Tobias Smollett and John Keats (both medically qualified), the Brontë sisters and Katherine Mansfield, Frederic Chopin and Robert Schumann, Antoine Watteau and Amedeo Modigliani, to name just a few — becomes at times distracting, and some readers may be inclined eventually to pass over this material, much of which is well known, as they try to follow the evolution of the scientific aspects of the disease. In this sense, Dormandy, a pathologist, surely follows too literally the advice of ”context, context, context” given to writers of history.

A few smaller points need notice. First, Dormandy writes well and pleasingly; the few flaws such as the consistent misuse of ”regime” for ”regimen” and the elementary error in the sentence ”the intensity of the contagion in such cases must have been intense” may be excused because the book is readable and well organized. Second, the few typographical errors are of minor significance. Third, and less excusable, is the absence of a list of primary and secondary sources. There is a bibliography, but this is, as Dormandy himself notes, ”a personal selection,” and is by no means complete; in a couple of instances the bibliography failed to provide me with the answer to a query. But it is also true that Dormandy makes extensive use of footnotes. These are informative and often witty, and being located at the bottom of each page are readily understood in the context of the main text. For myself, it is the footnotes rather than the content of the text that I will remember — an indication that this history of tuberculosis, despite its length, provides few insights that are not contained in shorter recent accounts of the disease.

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