Farewell To The East End

TUBERCULOSIS

Tuberculosis is as old as mankind. Evidence of the disease has been found in a Neolithic burial ground near Heidelberg, Germany and in mummies from Egyptian tombs 1000 years BC; and Hindu writings refer to ‘a consumption’. Hippocrates used the word phthisis to describe the cough, wasting, and ultimate destruction of the lungs. The disease is universal, and bears no relation to climate. It has been found in native tribes of North America, in primitive African tribes and amongst the Inuits of Alaska; China, Japan, Australia, Russia, Corsica, Malaya, Persia have all known it. There is probably no tribe or nation on earth that has been free from tuberculosis.

The disease has waxed and waned throughout recorded history, usually starting unnoticed, then reaching epidemic proportions, then waning as the population acquires collective immunity to the tubercle bacillus, over approximately a 200-year cycle. In Europe and North America it reached epidemic proportions between around 1650 to 1850 (varying somewhat from nation to nation), and it has been confidently concluded by medical scientists and historians that at the height of an epidemic 90 per cent of any population would have been infected. Of this number 10 per cent would have died. The lungs are the main focus of the bacillus, but they are not the only target; the meninges, bones, kidneys, liver, spine, skin, intestines, eyes – practically all human tissue and organs can be and have been destroyed by tuberculosis. It was called ‘the Great White Plague of Europe’.

Historically, the highest morbidity from tuberculosis occurred between the ages of fifteen and thirty. Throughout European literature of the eighteenth and nineteenth centuries the tremendous creative outburst of the ‘Sturm and Drang’ writers and poets of the Romantic movement dominated the public imagination. Today we look back on their sickly characters, amazed at apparently healthy young women fainting and going into a terminal decline, or languorous youths too weak to do anything much except sit around looking pale and interesting and writing poetry. But this was no morbid fantasy. Lassitude, weakness, weariness, loss of weight and colour were common amongst the young, and they were early signs of infection, unrecognised by most people. By the time coughing, fever and lung haemorrhage occurred the condition was called consumption, and it was too late for effective treatment. The flower of youth was gathered in its prime.

From ancient times there has been a belief that some relationship exists between tuberculosis and genius. The intellectually gifted are the more likely to contract the disease, and the fire which consumes the body makes the mind burn more brightly. Throughout Europe in the eighteenth and nineteenth centuries, the idea was fostered in the public imagination that consumption was the product of a sensitive nature and a creative imagination. Did not famous musicians, poets, painters and authors die from consumption? The tenuous connection was widely accepted with gratitude by those grieving the death of an only son or a beloved daughter. Grief needs an outward expression, and if a mother can interpret a few morbid poems written by her dying son as evidence of a genius snatched too soon from the world, she is somewhat comforted.

Indeed the immense creativity of this period of European history might have been an indirect product of tuberculosis. Opium was widely prescribed for the control of coughing, and it has been said that many consumptives who could afford it were addicted to opium. Many drugs are hallucinogenic, but not all arouse creativity as opium does.

Dwellers in the cold North assumed that grey skies, foggy winters and biting winds caused tuberculosis. Therefore the consumptive rich flocked in droves to Southern climates, trying to escape the cold North, but to little avail. They carried the seed of death with them and spread it amongst their hosts. In the South of France, Nice, once a pretty fishing village, suddenly became fashionable. Hotels were built, and filled with cadaverous consumptives, ghostly pale, with sunken features and haunted eyes. It was said that performances at the Opera House could not be heard above the sound of coughing and spitting! Rich Americans fled south to Florida and New Mexico to beg of the sun a last ray of hope. But the sun had no healing powers to cure advanced galloping consumption; in fact, exposure to the sun could have a negative effect.

Medical advice changed. Mountain air was prescribed – desert air, sea air, tropical air, moist air, dry air, gentle winds, fierce winds, no wind. Consumptives who could afford to do so journeyed hither and thither in vain. By the end of the eighteenth century it was obvious to everyone that tuberculosis did not respond to any climatic conditions, and respected no geographical boundaries.

Medical science was in its infancy, and treatments were rudimentary. The unpredictability of the course and outcome of tuberculosis had always baffled doctors – some consumptives died within months of contracting the disease, others recovered spontaneously with no treatment, whilst some lived a long and active life with intermittent bouts of debility. The sick begged for treatment; anything that might offer a glimmer of hope was clutched with shaking hands. But the outcome of the treatment was as unpredictable as the disease itself, and probably had little effect upon the course of the illness anyway. Despite that, one fashionable treatment followed another. Bleeding and blistering were common, as were leeches, plasters and poultices, cuppings and inhalations. Lifestyle was tackled, and various courses advised: vigorous exercise, such as skiing, riding, walking, or sea bathing sometimes helped. Deep breathing was advocated, also flute playing and singing. Other physicians insisted that rest was essential – total bed rest for months or years on end, often in an enclosed, heated room in which it was forbidden to open a window. Elizabeth Barrett lay in bed for years until Robert Browning romantically carried her off to Italy, where she spontaneously recovered!

Diet is important in any illness, and dietary fads followed each other with bewildering speed. Some physicians advised extreme abstention – a starvation diet we would call it today – and the Bronẗ sisters almost certainly suffered from malnutrition, imposed by their father and his medical advisers. Others went for diets rich in meat, offal, warm animal blood, fat, cream, fish, eggs and milk – asses’ milk, goat’s milk, camel milk, sheep’s milk and human milk (still favoured in the United States in 1900). All have had their day.

Drug therapy was almost non-existent. Ancient herbal remedies existed in every culture or tribe from time immemorial, some of which would ease symptoms, but none of which could destroy the tubercle bacillus. In the eighteenth and nineteenth centuries digitalis, quinine and mercury were used, although the universal balm and comforter was opium.

The great flaw in all treatments was the fact that the highly contagious nature of tuberculosis was not recognised. No special precautions in the care of a dying consumptive were advised by physicians. Quite the contrary, a hot stuffy room, with windows never opened, was favoured. Many are the testimonies of a loving parent or sibling who spent whole days and nights in the same room, and often in the same bed, as the sufferer. Millions of people who showed no signs of disease were carriers.

If all the money in the world could not protect the rich from the ravages of tuberculosis, what became of the labouring poor? Not for them the luxury of hotels in southern France or Alpine Switzerland, or even the cost of a doctor. They could barely afford an aspirin, or a day off work. Loss of work could spell destitution, so they laboured on until they died.

In industrial cities, firstly in England and later throughout Europe and America, crowded into factories and workshops, cold, half-starved men, women and children laboured for twelve or more hours a day in enclosed, foetid conditions and returned at night to tenement dwellings the sanitary conditions of which were beyond our imaginings. Infection would have passed with rampant speed from one sad individual to another, made more livid and virulent by the physical debility of the victim, caused by overwork and malnutrition.

In previous centuries all over Europe, child labour was the norm. From 1750 onwards, in industrial Europe, children were confined in closed, ill-ventilated rooms, working up to twelve hours a day. The Royal Commission on Child Labour in Manufacture of 1843 described children of seven and eight years as ... ‘stunted in growth, pale and sickly; the diseases most prevalent are disorders of the nutritive system, curvature of the spine, deformity of the limbs, and diseases of the lungs, ending in consumption’. The number of deaths from tuberculosis amongst these children may not even have been recorded. They were child paupers, frequently gleaned from workhouses, unwanted, unprotected, endlessly expendable.

In the enclosed workhouses of Britain, where inmates were confined and not allowed out, contagion would have been a continuous fact of life. The only record I have been able to find of the incidence of tuberculosis in a workhouse was from one in Kent, where in 1884 it was recorded that all of the seventy-eight boy inmates suffered from tuberculosis, and that amongst ninety-four girls only three could be found who were not infected. It has not been recorded how many of these workhouse children died, but many would have. Undoubtedly the worse the living conditions, the worse the effects of the tuberculosis bacillus. In the Jewish ghetto of Vienna, at the height of the epidemic, it was recorded that 100 per cent of the dwellers were affected, of whom 20 per cent died. The rich Viennese were terrified to go anywhere near the area.

For the poor, consumption was not the romantic image of pale, wasting youth. It was not the occasion to lie in bed for months on end, writing long, sad poems. It did not lead to extended travel abroad. No, indeed; for the labouring poor consumption was the great killer, the breeder of destitution, the father of orphaned children.

While the highest mortality from tuberculosis occurred in young adults, children also died. In the graveyard of Burton on the Welsh Borders, where my father and grandparents are buried, can be found the tragic memorial to ten children from one family who died between the ages of six months and twelve years from ‘wasting consumption’. The composer Gustav Mahler was one of fourteen children, seven of whom died of tuberculosis. The Masterton family, whose tragic story I tell, were not the only ones with such a history. In the tenements of Poplar lived the parents of six children, all of whom, I was told, had died of consumption. The prevalent sadness of the parents is, to this day, alive in my memory.

Contagion – the possibility of the spread of disease from one person to another by some unseen agent, but especially by breath – was not part of medical thinking at the time. Consumption was considered to be an hereditary malformation of the lungs, and the fact that so many families were consumptive lent weight to this theory. Strangely, the equally observable fact that, inside closed religious orders, where monks and nuns were not related, up to 100 per cent could be found to be infected, did not prompt physicians to pursue another line of thought.

However, in 1722 an English physician, Benjamin Marten, published a paper postulating that ‘a species of animalculae, or wonderfully minute living creatures, capable of subsisting in our bodies, may be fretting and gnawing at the vessels of the lungs’. The idea was considered so preposterous that the medical thinkers of the time refused to believe it. Had Marten’s hypothesis been accepted, and proper isolation and decontamination procedures been adopted, the Great White Plague of Europe might never have occurred.

In 1882, the German scientist Robert Koch, in a home-made laboratory, isolated the tuberculous bacillus for the first time and demonstrated by animal experiments that the bacillus was responsible for the disease that had baffled generations of researchers and medical thinkers. He also demonstrated that the bacillus could cross from man to animals and vice versa, thus proving that milk from tuberculous cows could infect human beings, especially children.

From that time onwards, massive public health programmes were ordered in all European countries and in America. The public were instructed in the facts of infection and contagion, which were completely new concepts for them to grasp. The strange and novel process of sterilisation had to be taught. Limiting the spread of infection was the order of the day, and this continued for nearly eighty years.

Pasteurisation of milk was started in the 1920s. This was nearly forty years after Koch had demonstrated the cross-infection from animals to humans, but even then a great many people would not believe it and refused to buy pasteurised milk. TB testing of cattle was at first voluntary for farmers, but became obligatory in the 1930s. In the 1920s large notices saying ‘SPITTING PROHIBITED’ were displayed in all public buildings, meeting places, and on public transport – and these notices were still displayed in the 1950s and ’60s. All pubs and private bars, such as those in golf and tennis clubs, had a spittoon in the bar.

Consumptives were removed from the workplace; even the idle rich were no longer free to wander around the South of France infecting others; they had to be treated in isolated sanatoria. Medical and nursing staff were specialists. Strict barrier nursing of TB patients was undertaken, and TB nurses did not enter general hospitals. A consumptive parent was removed from his or her children. A consumptive child was removed from school. Due to these measures tuberculosis, which had terrorised Europe, began to lose its grip.

The possibility of vaccination was considered. Vaccination against infectious disease was first developed in 1796 by Edward Jenner, who had observed the link between cow-pox and human smallpox. In the 1880s, when Robert Koch discovered the tuberculous bacillus, he held out great hopes that a vaccine could be prepared from dead tuberculous bacilli. This should have gone well, but, in the early use of the treatment, tragedy struck. A batch of the vaccine had been improperly prepared, and living bacilli were injected into a large group of children, all of whom contracted tuberculosis, and many of whom died. This disaster halted the use of a vaccine for over sixty years, and a safe and effective treatment had to wait until the 1950s, when the BCG (Bacillus-Calmette-Guerin) strain became available for the prevention of tuberculosis.

But a vaccine is preventative, not curative for those already infected. In the first half of the twentieth century many curative drugs were developed and used. In the 1930s sulphanilamide was tried; in the 1940s para-animo-salicylic acid; in the 1950s streptomycin was the first of the antibiotics to be introduced, and this one saved millions of lives.

X-rays were invented as long ago as 1895, and could determine the extent of the disease. Surgery was attempted, and by the 1930s was relatively well advanced, from removal of a whole lung to removal of one or more diseased lobes of the lungs. Thoracoplasty and artificial pneumo-thorax, aimed at resting the lungs, was attempted in the 1890s and developed throughout the early part of the twentieth century.

But it was the public health programmes carried out over eighty years that were chiefly responsible for success, and by the end of the 1960s tuberculosis was no longer a major cause of death in European countries and America.

We, the favoured few of the twenty-first century, do not, cannot know the dreadful impact that tuberculosis had in days gone by. Let us be thankful for the advance in medical knowledge, and let us strive to extend it worldwide.[12]