The pale avenger

The White Death: A History of Tuberculosis

Thomas Dormandy <em>The Hambledon Press, 433pp, £25</em

Medical students today still learn about diseased tissue by observing pickled specimens preserved in glass "pots". In the pathology museum at Cambridge University most of the pots were produced early this century. Charles Saatchi would probably pay millions to grab hold of such an extensive collection of Hirstian "old masters". A bright student I know, back in 1990, sneered at these fine antiques, containing abundant tuberculous tissue, as being about as useful to him as the finer points of dodo identification are to an ornithologist. Two years after his qualification a remarkable thing happened. Having hacked through the chest of the cadaver of a middle-aged, homeless male he was confronted with an unmistakable sight. A series of grain-like cavities perforated the lungs, just like something from the maligned old TB pots. A real case of tuberculosis. Since then he has been carving up half a dozen or so such cases each year. Tuberculosis is no longer a disease of the past.

The classic study of TB, The White Plague, was published by Rene and Jean Dubos in 1952, but never made it to a second edition. Thomas Dormandy's The White Death is a timely successor. So what is so white about this disease? Its victims assume an ashen, anaemic countenance (look at portraits of Robert Louis Stevenson). In the 19th century, TB was bizarrely associated with purity and innocence, killing as it did so many children and poets. The fashionability of pallid pre-Raphaelite models led many otherwise healthy young women to adopt starvation diets and chemically whiten their skin to mimic the sickly hue of consumption.

Most literary biographers would relish the opportunity of drawing links between Keats and Kafka, Beardsley and the Brontes, Chekhov, Lawrence, Orwell and Thomas Mann. Dormandy does so with impressive ease. Sometimes you feel it is hard to find a great writer who avoided consumption. Keats and Chekhov were both medically trained and poignantly understood the horrors associated with their condition. Chekhov's final four plays cryptically portray the insidious personal and social effects of TB. Keats's "Ode to a Nightingale" - "where youth grows pale, and spectre thin, and dies" - describes the disease in typically florid terms. And "La Belle Dame Sans Merci" could herself have been the disease, carrying off pale, fast-withering knights.

Before the discovery by Robert Koch in 1882 that a bacterium was responsible for TB, superstition abounded. Florence Nightingale attributed symptoms to the overuse of re-breathed air in confined spaces. Poor old Keats even wondered if it was linked to excessive masturbation.

Tuberculosis arrived in earnest with the industrial revolution. The emergence of cities, filth and persistent human contact fuelled the disease, which had been bubbling away in man since ancient times. Necessity is the mother of invention, so scientific advances against tuberculosis were inevitable. The stethoscope allowed physicians to hear the perilous state of consumptive lungs, and X-rays allowed visualisation. Diagnosis was all well and good but without cures, for much of the 19th and early 20th centuries, rest and fresh air were the only prescription. Hence the sanatorium movement was born to fleece wealthy consumptives.

Many of us will remember queuing at school for our TB jab. The resulting bump and scar on the shoulder became a source of playground misery once the bullies realised how painful the flimsiest of punches could be. But the vaccine was of vanishingly small use. It was pushed forward by its vociferous French inventor between the wars, in spite of protestations from les anglosaxons, who always disputed the validity of its early trials.

Dormandy smartly reminds us that TB was (and is) predominantly a disease of destitution, claiming the lives of one in 14 humans. Sub-Saharan Africa boasts a large proportion of today's cases, although in the mid-19th century David Livingstone was struck by its absence. Cecil Rhodes was diagnosed with consumption in 1870, and left Oxford for warmer climes, joining his brother in South Africa. He found diamonds, annexed a country and introduced the disease from which he eventually died. In 1988, during his incarceration, Nelson Mandela came close to dying from tuberculosis.

Effective treatment for TB finally arrived in the 1940s with the discovery of streptomycin in America. Nye Bevan, as health minister in 1947, at the request of David Astor, opened the way to bring one of the first samples of the antibiotic to Europe to treat George Orwell, who proved allergic to the drug. He died three years later. Other drugs emerged, and from the 1950s to the 1980s most people in the west genuinely believed we were living in a post-infectious society.

Two things have happened over the past 20 years to smash our complacency. Bacteria have evolved resistance to antibiotics and many immune systems have been weakened with the appearance of the HIV virus. The "fourth world", comprising a displaced underclass, has emerged in the west. Five per cent of London's homeless carry tuberculosis, and many carry the Aids virus, too. Occasionally they receive treatment but seldom enough to kill the bacteria. In these conditions drug-resistance grows. It is a fertile environment for the development of new strains of uncertain infectivity. The future may be bleak, but it need not be. The entire genome of the tuberculosis bacterium has been sequenced and a series of new drug targets and vaccine candidates have emerged. The pharmaceutical industry, however, remains obsessed with a Prozac-happy, Viagra-priapic, Zantac-desatiated world. New reagents in the fight against infection are appearing more slowly than are bacterial strains resistant to current drugs. Dormandy's message is clear: we ignore contagion at our peril.

Dr Michael Barrett is a lecturer in the institute of biomedical and life sciences at Glasgow University

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