by Sean Martin
The White Death was, of course, tuberculosis. The poet – and medical student – John Keats wrote of ‘the weariness, the fever, and the fret’ in ‘Ode to a Nightingale’. It was a reference that was at once both autobiographical and prophetic: his mother and brother died of tuberculosis (in 1810 and 1818), and Keats himself died of TB in Rome in 1821, at the age of 25. The disease was a death sentence at that time. When Keats coughed up blood in February 1820 – the first sign that he was ill – he knew immediately what it meant. ‘I know the colour of that blood,’ he told his friend and roommate Charles Brown. ‘It is arterial blood; – I cannot be deceived in that colour; – that drop of blood is my death-warrant; – I must die.’
Tuberculosis is one of the oldest diseases known to humanity. As we saw in Chapter 1, paleopathological remains from the submerged Neolithic village of Atlit Yam off the coast of Israel suggest the disease has been plaguing humans for at least the last 9,000 years. TB has left a long trail across many medical texts from antiquity, too. Babylonian, Assyrian, Chinese, Hindu, Greek, and Roman sources all describe the disease. The earliest description of tuberculosis may be Chinese from as early as 2700 BC, while in the West, the Hippocratic writings refer to it as phthisis, which they believe to have been caused by ‘evil air’. Hindu texts from around 1200 BC describe treatment for pulmonary TB, as do Mesopotamian writings from the seventh century BC.277 And in that time, TB has been known by more names than just the White Death, phthisis and consumption. Depending on what part of the body it attacks, it has also been known as scrofula, Lupus vulgaris (the common wolf) and Pott’s Disease.
Behind these names is a chronic bacterial infection, caused by the bacillus Mycobacterium tuberculosis. It can affect cattle as well as humans (Mycobacterium bovis), and it was long thought to be a zoonosis. Now research suggests that either humans gave TB to cattle – a process known as anthroponosis or reverse zoonosis – or that the human strain emerged before the bovine.278 TB can affect almost any organ of the human body, as well as the central nervous, circulatory and lymphatic systems, and can also attack the bones and joints, the spine (when it is known as Pott’s Disease) and the skin (cutaneous TB, one of whose forms is lupus vulgaris). Its most common form is pulmonary tuberculosis, when the bacillus attacks the lungs and is spread from person to person through airborne droplets. (Keats is thought to have contracted the disease from nursing his brother Tom, who died just over a year before Keats himself became ill. Such a relatively long incubation period is not uncommon with TB; some can be much longer.) Symptoms include coughing, bloody sputum, night sweats, weight loss and difficulty breathing. In this incarnation, the disease was known as the White Death, consumption and the graveyard cough.
If the bacillus settled in the lymph glands, however, tuberculosis would manifest as glandular swellings around the neck. This form of TB was often the result of drinking milk from infected cows. (Louis Pasteur would change all that, as we will see.) It was simply a case of the bacilli, once inside the body, taking the shortest route to the closest lymph nodes. ‘Thus, bacilli ingested in contaminated milk would tend to manifest their presence in the neck and intestinal regions, whereas those inhaled would concentrate in the lungs.’279
In this form, tuberculosis was thought to be a separate disease known as scrofula, the King’s Evil or the Royal Disease, and had a longstanding association with royalty in England and France. It was not that monarchs of either country were thought to be particularly susceptible to the disease; on the contrary, they were thought to be able to cure it by the laying on of the Royal Hands. This appeared to work, as the swellings would often go down after being touched by the King or Queen, which might account for the longevity of the practice.
The Royal Touch, as it was known, is thought to have begun in France after Louis IX returned from crusade in 1254 (although it may also have had something to do with the French king’s saintly reputation: he was canonised in 1297). There is a further link between Louis, disease and crusade: that he went on crusade at all was said to be due to his recovering from a serious illness, an apparently miraculous cure. Disease, royalty and cure were therefore linked in the popular imagination. Henry III of England, keen to keep up with the man idealised as the most Christian of monarchs, began his own practice of ‘Royal Touch’ in the following decade. This was, significantly, the time of the Second Barons’ War (1264–67), in which Henry needed all the signs of royal authority he could get. The Royal Touch was one way of asserting the House of Plantagenet’s divine right to rule.
Indeed, England had its own saintly king, Edward the Confessor (1042–66), who was said to have had healing powers, and was proclaimed a saint in 1161. (The only English monarch to be canonised, as Louis was in France.) As Kenneth Kiple noted, ‘by taking up Edward the Confessor’s healing tradition, the Plantagenets were, in effect, linking themselves with saintliness… The political benefits from such efforts could be enormous.’280
Henry’s successor, Edward I, continued the practice and is known to have touched thousands of his subjects. Again, with Edward’s campaigns in Wales (the office of Prince of Wales as heir apparent to the English throne begins with Edward), involvement in the Scottish Wars of Independence, and expulsion of England’s Jews in 1290, the Royal Touch reminded the royal subjects that the King’s actions had divine sanction and could not be questioned. Christ had been a miracle worker and healer, so now was the king.
The Royal Touch continued to have political significance. It helped bolster dubious claims to the throne, or weak monarchs. Charles I (1625–49) made a return to touching his subjects after losing the civil war to the parliamentary forces of Oliver Cromwell, and was still performing the Royal Touch as late as October 1648, just three months before his execution.281 When the monarchy was restored in 1660, Charles II (1660–85) was urged by his physician Richard Wiseman to resume the practice of touching. It proved to be a popular move: the largest number of people touched was in 1684; so many, in fact, that a stampede ensued.
The touch continued in France, too, where the reigning Bourbons were becoming even more unpopular than Charles I and James II (1685–8) of England. The boy king Louis XV touched more than 2,000 people at his coronation in 1722. Louis XVI – the last French monarch before the 1789 Revolution – was perhaps the most avid dispenser of the Royal Touch of all the later Bourbons. (Not that it did him much good in the long run.) Interestingly, in territories where there was no concept of the divine right of kings – such as the German and Italian states – scrofula was hardly ever seen as a disease in its own right.
Queen Anne (1702–14) was the last British monarch to touch, despite being Protestant. Old habits were clearly dying hard. She touched the young Samuel Johnson in 1712, although he wasn’t cured. Nonetheless, Johnson kept his ‘touch piece’, a gold coin minted for the occasion and threaded on a white ribbon that the Queen hung round the necks of all 300 people touched that day. Johnson wore his for the rest of his life.282
By the time Keats died from pulmonary tuberculosis, scrofula was a political antique, and would soon become a ‘nosological antique’ too. August Hirsch still used the term (he was writing in the 1860s),283 although it was becoming increasingly apparent scrofula was a form of tuberculosis, not a separate disease. A new vocabulary was needed ‘because of increasingly strident demands for a new precision from physicians determined to transform medicine from an art to a science.’284
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Medicine’s transition from an art to a science had been going on in fits and starts since the time of Paracelsus and Vesalius. The word ‘tubercle’ was first used in 1689 by the English physician Richard Morton (1637–98), in his treatise Phthisiologia. He used it to describe the small nodules of inflamed tissue that were found in the lungs of people who had died of what, in Morton’s time, was still being referred to by the Greek word phthisis.
Hippocrates believed phthisis was caused by ‘evil airs’. In the sense that pulmonary TB is spread by droplets, coughed, sneez
ed or otherwise expectorated from person to person – it can even be transmitted when speaking – Hippocrates was quite right. But as cities grew in the nineteenth century as a direct result of the industrial revolution, ‘evil airs’ began to spread. For the better off, tuberculosis in its pulmonary form was often seen as the result of a sensitive disposition, or heredity. For the less well off, no such niceties could be entertained. Pulmonary TB afflicted ‘hardworking people’ (to borrow a phrase from our hardworking politicians), and hit them hard.
If Hippocrates had come back in the nineteenth century, he would have been horrified by the ‘airs, waters and places’ he would have seen. As little towns darkened into big cities, the airs were choked up by smog from Blake’s dark satanic mills, the waters fouled by inadequate sewerage and faulty drainage, and places for living and working reduced to little better than Newgate Prison had been at the time of the smallpox experiments, rendered almost uninhabitable by overcrowding, dirt, damp, dust, poor or non-existent ventilation, and cold. But of course, such buildings were far from uninhabited: despite the conditions, the poor did not have the luxury of leaving. Under these conditions, pulmonary tuberculosis became one of the great endemic diseases of the nineteenth century, and the crowded, dirty city became its favoured breeding ground.
Getting away from the city for cleaner air was one of the recommended treatments. In Nicholas Nickleby, when Smike contracts tuberculosis, Nicholas is advised ‘that the last chance and hope of his life depended on his being instantly removed from London.’ Nicholas takes his friend to ‘that part of Devonshire in which Nicholas had been himself bred’ on the grounds that it was ‘the most favourable spot’.285 Becoming more wracked by the disease each day, Smike has a vision of conditions which were the very opposite of the great urban breeding grounds of tuberculosis:
He fell into a light slumber, and waking smiled as before; then, spoke of beautiful gardens, which he said stretched out before him, and were filled with figures of men, women, and many children, all with light upon their faces; then, whispered that it was Eden – and so died.286
Such beautiful gardens were beyond the reach of most TB sufferers in the nineteenth century; Smike was lucky in that at least he got to spend his final weeks away from London and its fatal filth. For the urban poor who were not blessed with friends like Dickens’s hero, there was little they could do.
Various treatments had been tried over the centuries. The Greeks and Romans favoured balancing the humours through diet, drugs, changes in lifestyle, and surgery.287 A wholesome diet was thought to be beneficial, as nourishment was thought to combat the ‘consumption’ of the body. Freshness was encouraged in food, especially milk (from any source, animal or human). In her history of tuberculosis, Helen Bynum recorded some of the further dietary treatments, including hyssop and fleawort boiled in sour wine; horehound, pine nuts, parsley and pepper with honey; and inhaling ‘the fumes of ivy’. Galen had a potion that was comprised of a pound of mountain squill plant, soaked for a month in vinegar, and then administered each morning ‘when patients had to be brought back from the edge of despair.’288 Fasting was recommended sometimes, but had to be practised cautiously in case it encouraged further consumptive wasting. Unlike in ancient remedies for epilepsy, bathing was encouraged. Myrrh oil with lupines could be applied to the feet, and then replaced with butter. Gentle exercise was also encouraged, provided the patient didn’t overdo it. Surgical procedures mainly involved bloodletting, especially if the patient was spitting blood. Humoural theory dictated that spitting blood was due to a build-up of blood, therefore bleeding was the logical remedy.
Further aid could come in the form of a change of air: ‘This was no two-week pick me up in the sun, but the sombre search for a dryer, lighter climate with gentle, favourable winds.’289 It would be beneficial if the journey involved travel by boat. ‘Sea voyages were considered intrinsically healing because of the motion of the boat, including nausea (purging) and exposure to sea air, particularly when patients were spitting up blood. If this was beyond the patient’s strength (or purse), a sojourn to the nearest coast should be attempted.’290 Failing that, fresh air must be got into the patient’s room. So if the patient couldn’t afford a trip to Egypt or Libya, the doctor would have no option but to simply leave the door to their room open.
After the end of classical antiquity, methods did not change very much. The Arabs recycled and adapted Hippocrates and Galen in their own way, as they had with other diseases. Isaac Judaeus (c. 840–932) and Avicenna (980–1037) both wrote on tuberculosis, although some of their treatments were specific to their countries and climates.
We are unsure of rates of infection in the Middle Ages. As Helen Bynum noted, a French archaeological dig exhumed 2,498 skeletons from seventeen burial sites dating from the fourth to the eleventh centuries, revealing an inferred rate of infection of 1.2 per cent (29 of 2,498).291 ‘This figure is thought to be low in comparison with modern rates.’292 Such a low rate of infection indicates both the rural nature of life in the early Middle Ages, tuberculosis’s difficulty in spreading in such small communities, where the chain of infection was likely to die out, and also the disastrous effect urbanisation had on human health in the eighteenth and nineteenth centuries, when it is thought that virtually all city dwellers were infected with the TB bacillus.293 One development in the natural history of disease that may have helped TB in the Middle Ages was its dominance over leprosy, as noted in Chapter 3. A theory emerged in the 1940s proposing that TB gave immunity from leprosy, but new evidence from DNA studies of human bones from the first to sixteenth centuries might offer an alternative explanation. The study showed that leprosy sufferers were often coinfected with tuberculosis as well, and it has been suggested that TB, being faster-acting, killed the sufferers before leprosy was able to.294
Regardless of precisely how tuberculosis gained its foothold, it had become widespread by the early nineteenth century, as revealed by advances in medicine. The French doctor René-Théophile-Hyacinthe Laennec (1781–1826), the inventor of the stethoscope, observed the damage wrought by the disease during post mortems. He found tubercles in patients’ intestines, livers, spleens, kidneys, glands, on the skin and in the membranes around the brain and spinal cord. It became clear that phthisis, consumption, lupus vulgaris, scrofula and Pott’s were different manifestations of the same disease. In the 1830s, the word ‘tuberculosis’ was introduced into medical usage by Johann Lukas Schoenlein (1793–1864), a professor of medicine at Zurich, an acknowledgement that these various tubercle-producing afflictions were all part of the same condition. But the precise nature of the disease still drew no clear consensus from the medical profession. As the composer Frédéric Chopin wrote,
I have been sick as a dog these last two weeks; I caught cold in spite of 18 degrees of heat, roses, oranges, palms, figs and three most famous doctors of the island [he had gone to Palma in Majorca for health reasons]. One sniffed at what I spat up, the second tapped where I spat it from, the third poked about and listened how I spat it. One said I had died, the second that I am dying, the third that I shall die.295
Typhus
Tuberculosis was just one of a group of diseases that flourished in the squalid conditions of the nineteenth century city. Typhus, for instance, was ever present. The link between squalor and typhus was not lost on the German epidemiologist August Hirsch, who wrote that ‘The history of typhus… is the history of human misery.’296 The disease thrived anywhere dirty or crowded, as its nicknames testify: jail fever, ship’s fever, camp fever.
London, like all cities, had suffered repeated typhus epidemics. At the Old Bailey in 1750, the passageway connecting Newgate Prison with the courtroom was so overcrowded with lousy prisoners waiting to be tried it had caused an outbreak. Typhus did the hangman’s work for him, killing one third of Newgate’s inmates in the outbreak. But it was no respecter of class: two judges, the lord mayor, aldermen and other court officials were also taken. A report blamed the outbreak
on overcrowding and filthy conditions caused by the ‘horrid neglect of gaolers, and even of the sheriffs and magistrates, whose office it is to compel the gaolers, to the most rigorous repeated orders and attention to their duty’.297
These courtroom flare-ups were known as ‘Black Assizes’ and had been a feature of law and order since the sixteenth century. In 1577 the trial at Oxford of a Catholic bookbinder, Rowland Jenks, had been afflicted. He had been accused of disseminating ‘Popish’ books, and the ensuing scandal had resulted in far too many people attending the trial to see the bookbinder receive his just desserts. Typhus took advantage of the crowded courtroom, and around 400 people are thought to have died as a result of attending the trial. Jenks got off lightly by comparison: he only had his ears cut off.
One solution to the Black Assizes would have been to install more windows, not only at Newgate and the Old Bailey, but in other court rooms and prisons across the country, and in any building likely to be crowded, such as tenements. However, due to the 1696 window tax, this was beyond the financial reach of many; even the better off were forced in some cases to brick windows up. (The tax remained in place until 1851.)
The German doctor Rudolf Virchow (1821–1902) found similar problems when he visited Upper Silesia in 1848. Virchow studied an epidemic of typhus in the region, and found that peasants were living in squalid conditions, and were infected with body lice but refused to bathe. They subsisted on a meagre diet of potatoes and vodka, which did nothing to strengthen their immune systems.
Port cities could also be particularly susceptible. New diseases could be frequently brought in by ship – crew, passengers, cargo or the ubiquitous ship’s rats could all act as vectors. The Black Death might be the most significant occurrence of infestation through ports, but it was certainly not the last. Both Liverpool and New York were hit by a typhus epidemic in 1847. Despite the fact that the Atlantic Ocean separated the two cities, both epidemics had the same cause: immigrants fleeing the great famine in Ireland.
