WEBVTT 00:02.250 --> 00:03.620 Prof: Good morning. 00:03.620 --> 00:08.120 Our topic for this time, and next, is another of the 00:08.119 --> 00:13.679 really ancient diseases in our course, which is tuberculosis. 00:13.680 --> 00:18.460 Tuberculosis was present in Ancient Egypt. 00:18.460 --> 00:24.030 This is known from skeletons and from mummies. 00:24.030 --> 00:28.590 And it seems that tuberculosis has been with human beings ever 00:28.590 --> 00:33.300 since they first began to gather in substantial settlements, 00:33.300 --> 00:35.910 which are essential for its transmission, 00:35.910 --> 00:38.240 in ways we'll be discussing. 00:38.240 --> 00:42.410 It was present in Ancient Greece, and in Rome, 00:42.410 --> 00:47.600 and Hippocrates and Galen clearly knew patients suffering 00:47.600 --> 00:49.640 from tuberculosis. 00:49.640 --> 00:52.250 It persisted in the Middle Ages. 00:52.250 --> 00:57.460 So, we're dealing not with a new but a very ancient disease. 00:57.460 --> 01:01.470 A question that you'll be asking is whether indeed it's an 01:01.465 --> 01:05.615 epidemic disease; would it perhaps be better to 01:05.623 --> 01:07.963 describe it as endemic? 01:07.959 --> 01:10.979 And this again, I think, as when we dealt with 01:10.980 --> 01:13.970 malaria, we see that some diseases are 01:13.968 --> 01:18.388 both endemic and epidemic, and I think this applies to 01:18.393 --> 01:20.233 tuberculosis as well. 01:20.230 --> 01:26.090 One way of thinking of it might be in terms of its time frame. 01:26.090 --> 01:30.370 If you look at any single generation, it often seems that 01:30.373 --> 01:33.513 tuberculosis isn't an epidemic disease. 01:33.510 --> 01:37.390 It's present, after all, year after year. 01:37.390 --> 01:42.730 It is contagious but it spreads slowly from person to person. 01:42.730 --> 01:48.200 Its course in the individual body of a patient is often very 01:48.200 --> 01:50.240 slow and capricious. 01:50.239 --> 01:54.509 It's clearly different from bubonic plague, 01:54.510 --> 01:58.170 from influenza or Asiatic cholera. 01:58.170 --> 02:03.220 But if you take a long-term perspective, it might seem that 02:03.215 --> 02:08.345 tuberculosis does ebb and flow, like an epidemic disease. 02:08.348 --> 02:12.648 Perhaps one could think of it in terms of an epidemic that 02:12.652 --> 02:17.512 lasts for centuries, perhaps, or decades in the case 02:17.508 --> 02:22.938 of a body of a single patient, at times. 02:22.938 --> 02:27.578 In a sense, one could say that tuberculosis could be an 02:27.579 --> 02:30.499 epidemic disease in slow motion. 02:30.500 --> 02:36.110 Our concern will be with Europe and North America, 02:36.110 --> 02:40.460 at a time of a vast upsurge--and here I'm referring 02:40.455 --> 02:44.435 to Western Europe-- that coincided with the 02:44.435 --> 02:46.585 Industrial Revolution. 02:46.590 --> 02:50.690 Here there are a number of factors that lie in the 02:50.686 --> 02:54.026 background that contributed, probably. 02:54.030 --> 02:59.680 One is a large-scale pace of urbanization, 02:59.680 --> 03:03.350 and we'll see the impact of crowded housing and poor 03:03.349 --> 03:06.299 ventilation, which are decisive factors, 03:06.301 --> 03:10.121 particularly in the case of a disease that's a pulmonary 03:10.116 --> 03:13.136 disease, above all. 03:13.139 --> 03:17.669 The rise of sweatshops and the factory system again led to 03:17.665 --> 03:20.725 crowding, this time not in the home but 03:20.734 --> 03:24.684 in the workplace, and poor ventilation now during 03:24.675 --> 03:28.615 the day, as well as in the home at night. 03:28.620 --> 03:33.940 I'm thinking of low wages, and with that poor diet and a 03:33.941 --> 03:36.651 compromised immune system. 03:36.650 --> 03:41.340 Another factor that's very important for diseases that are 03:41.342 --> 03:45.132 respiratory is pollution of the atmosphere, 03:45.128 --> 03:49.668 and the smog in cities like London due to soot from the 03:49.670 --> 03:53.710 burning of coal, or particles due to tobacco 03:53.705 --> 03:56.675 from smoking, or again particles in 03:56.675 --> 03:59.595 mineshafts, or unhygienic workshops, 03:59.599 --> 04:02.999 all made their contribution. 04:03.000 --> 04:05.400 In any case, it's not by chance that 04:05.403 --> 04:08.333 England, the first industrial nation, 04:08.334 --> 04:12.914 experienced an epidemic wave that crested between the middle 04:12.914 --> 04:17.734 of the eighteenth century and the middle of the nineteenth. 04:17.730 --> 04:22.000 And then in the case of England, there was a slow, 04:21.999 --> 04:26.699 steady decline from the later decades of the nineteenth 04:26.704 --> 04:27.754 century. 04:27.750 --> 04:31.940 And we can see this as well taking place in countries that 04:31.937 --> 04:35.247 industrialized a little bit later, say France, 04:35.245 --> 04:37.225 Germany, Italy, Russia. 04:37.230 --> 04:43.100 The upsurge began later, but did so remorselessly. 04:43.100 --> 04:47.220 And then a decline set in, but again slightly later, 04:47.216 --> 04:50.926 from the beginning of the twentieth century. 04:50.930 --> 04:55.810 If you look at the geography of tuberculosis in Europe, 04:55.810 --> 05:00.840 it would also support this idea of a clear relationship between 05:00.843 --> 05:05.923 tuberculosis as a condition, and the conditions created by 05:05.915 --> 05:10.775 industrial development; especially in its traumatic 05:10.781 --> 05:12.211 early phases. 05:12.209 --> 05:17.129 Tuberculosis was a major killer in the northern industrial 05:17.129 --> 05:19.729 nations-- Britain, Germany and 05:19.730 --> 05:24.270 France--and it was less prevalent in less industrial, 05:24.269 --> 05:29.139 largely agricultural nations, such as Italy and Spain. 05:29.139 --> 05:32.649 So, there's this distinction to be made. 05:32.649 --> 05:37.479 But also if you looked at the pattern of tuberculosis in Italy 05:37.480 --> 05:41.390 and Spain, you would see not only was it 05:41.389 --> 05:44.729 less there, but also it respected the 05:44.726 --> 05:47.996 distribution of industrial development. 05:48.000 --> 05:49.490 Take Italy for example. 05:49.490 --> 05:52.860 We already talked, in the case of malaria, 05:52.855 --> 05:55.725 about a major north/south divide. 05:55.730 --> 05:59.070 This is also true with regard to tuberculosis, 05:59.074 --> 06:00.344 but in reverse. 06:00.338 --> 06:02.708 Tuberculosis, in other words, 06:02.706 --> 06:07.606 was an affliction above all of Italy's northern cities, 06:07.610 --> 06:13.570 and it was much less prevalent in the agricultural south where 06:13.567 --> 06:16.007 people worked outdoors. 06:16.009 --> 06:20.279 Well, let's turn now to the nature of the disease: 06:20.278 --> 06:23.848 how it's transmitted, its different forms, 06:23.851 --> 06:27.251 and its symptomatology in the body. 06:27.250 --> 06:29.760 The pathogen, to begin with, 06:29.757 --> 06:34.587 was first discovered by someone we know well now, 06:34.589 --> 06:39.489 in a variety of contexts, and this is Robert Koch, 06:39.490 --> 06:44.290 who discovered it in 1882--the Mycobacterium 06:44.285 --> 06:51.605 tuberculosis, which is that. 06:51.610 --> 06:57.060 Now, transmission--tuberculosis can be spread in more than one 06:57.055 --> 06:58.705 way, but we're concerned, 06:58.711 --> 07:01.911 and will be concerned, primarily with its dominant 07:01.910 --> 07:05.770 mode of transmission, which is through the air. 07:05.769 --> 07:11.719 In other words, a sufferer from tuberculosis 07:11.721 --> 07:15.601 will say cough, sneeze, spit, 07:15.598 --> 07:24.178 and give off airborne droplets, which are then inhaled by other 07:24.180 --> 07:25.980 people. 07:25.980 --> 07:32.070 Now, a primary infection by most people who come into 07:32.071 --> 07:39.221 contact with Mycobacterium tuberculosis doesn't lead on 07:39.216 --> 07:43.196 to symptoms, it usually heals. 07:43.199 --> 07:47.089 But in those with compromised immune systems, 07:47.091 --> 07:50.101 the disease, as the expression was, 07:50.100 --> 07:51.870 is disseminated. 07:51.870 --> 07:54.610 It can then lie dormant for years. 07:54.610 --> 07:58.700 As I've said, one of the things about 07:58.704 --> 08:04.624 tuberculosis is its enormously capricious quality. 08:04.620 --> 08:08.720 Alternatively, it could produce disease within 08:08.716 --> 08:11.716 weeks of the primary infection. 08:11.720 --> 08:15.720 Mycobacterium tuberculosis can spread via 08:15.721 --> 08:18.971 the bloodstream, or the lymph system, 08:18.966 --> 08:23.606 to infect a variety of organs, and produce lesions in 08:23.612 --> 08:26.772 virtually any tissue in the body. 08:26.769 --> 08:32.249 I'll show you now a number of images of sufferers from 08:32.254 --> 08:35.674 tuberculosis, in various forms. 08:35.668 --> 08:39.138 And I'm hoping that these images won't be overly 08:39.144 --> 08:40.924 distressing to anyone. 08:40.918 --> 08:45.508 First, this is scrofula, sometimes called the 08:45.513 --> 08:50.423 "King's Evil," which was--here we have 08:50.419 --> 08:53.029 scrofula of the neck. 08:53.029 --> 08:58.799 There's tuberculosis of the skin, called Lupus 08:58.804 --> 09:00.614 vulgaris. 09:00.610 --> 09:04.470 Tuberculosis can also infect the meninges of the brain, 09:04.470 --> 09:06.570 the bone and joints, the kidneys, 09:06.573 --> 09:09.143 the urinary and reproductive system, 09:09.139 --> 09:14.109 and can infect the spine, leading to severe deformity and 09:14.114 --> 09:15.184 hunchback. 09:15.179 --> 09:19.309 I'll show you then that form; it's called Pott's Disease. 09:19.308 --> 09:24.488 And there's a skeleton from a sufferer of Pott's Disease--or 09:24.490 --> 09:28.180 this is what be what it would look like. 09:28.178 --> 09:33.578 The disease can also affect the lining of the abdominal cavity 09:33.581 --> 09:34.911 or the heart. 09:34.908 --> 09:39.418 But overwhelmingly, the most common form of 09:39.419 --> 09:42.749 tuberculosis is of the lungs. 09:42.750 --> 09:47.400 And this is what we'll be dealing with primarily in the 09:47.404 --> 09:51.804 course, pulmonary disease, also known as phthisis or 09:51.799 --> 09:53.179 consumption. 09:53.178 --> 09:59.568 We'll mention in passing that tuberculosis is also spread, 09:59.572 --> 10:04.282 and was spread, by meat or milk of infected 10:04.283 --> 10:08.803 animals; but that's a secondary tragedy 10:08.797 --> 10:14.917 within the larger dominant pulmonary form of the disease. 10:14.918 --> 10:18.298 Now, you know from your reading response questions, 10:18.298 --> 10:23.408 and from Barnes' book this week, that tuberculosis is 10:23.413 --> 10:27.843 sometimes referred to as a social disease, 10:27.840 --> 10:33.380 and you'll see in your in trays that I've just sent you an email 10:33.375 --> 10:38.205 about social diseases and how we might think of them. 10:38.210 --> 10:42.350 But just for the moment, you'll note that Barnes doesn't 10:42.351 --> 10:45.441 define what he means by social disease. 10:45.440 --> 10:52.360 By saying that it was a social disease, 10:52.360 --> 10:59.110 he's arguing that tuberculosis had a predilection for certain 10:59.113 --> 11:04.663 social classes, that it was a disease that was 11:04.663 --> 11:08.403 unlike-- that it didn't affect all 11:08.403 --> 11:10.233 classes equally. 11:10.230 --> 11:13.950 Now, note that cholera, for example, 11:13.953 --> 11:19.703 was a disease that didn't affect all social classes. 11:19.700 --> 11:22.450 Tuberculosis did, in fact, afflict royal 11:22.445 --> 11:24.495 families, aristocrats, 11:24.496 --> 11:28.216 artists, writers and professionals, 11:28.220 --> 11:32.470 and this was an important factor in the social response to 11:32.466 --> 11:33.506 the disease. 11:33.509 --> 11:38.149 Given the mode of transmission, that is, through the air, 11:38.145 --> 11:42.115 it was inevitable that that would be the case. 11:42.120 --> 11:46.370 So, even if we do decide to call tuberculosis a social 11:46.365 --> 11:50.205 disease, we need to make major qualifications. 11:50.210 --> 11:54.450 But to focus on the rich and famous is distorting, 11:54.445 --> 11:58.505 because out of all proportion, tuberculosis did, 11:58.506 --> 12:04.526 and still, afflicts the poor; especially the urban poor. 12:04.528 --> 12:08.678 Remember the risk factors we said: living in cities rather 12:08.682 --> 12:13.772 than the countryside; crowded, unhygienic housing; 12:13.769 --> 12:17.989 poor ventilation; workplaces that were similar to 12:17.994 --> 12:21.894 those of the home; child labor en masse; 12:21.889 --> 12:27.839 lowered resistance due to poor diet or pre-existing diseases. 12:27.840 --> 12:33.480 Tuberculosis then thrived in slums and tenements, 12:33.479 --> 12:39.239 among industrial workers, and among the inmates of 12:39.235 --> 12:43.225 almshouses, prisons, barracks. 12:43.230 --> 12:45.970 Let me give you some illustrations, 12:45.971 --> 12:49.281 and we'll look at some famous pictures. 12:49.279 --> 12:55.019 I think that we have no better ones than the photographs taken 12:55.023 --> 13:00.673 by Jacob Riis of tenements and sweatshops in New York City in 13:00.673 --> 13:05.293 the 1880s and nineties, some of which were collected in 13:05.285 --> 13:07.895 his really famous and influential book, 13:07.899 --> 13:11.629 How the Other Half Lives, that was published in 13:11.626 --> 13:12.116 1890. 13:12.120 --> 13:15.900 And I'd like to show you some of the pictures. 13:15.899 --> 13:21.879 This is a slide of a tenement, an ideal place for 13:21.879 --> 13:23.749 tuberculosis. 13:23.750 --> 13:27.100 We'll be looking first at some pictures of housing, 13:27.100 --> 13:31.120 and I'd like you just to make the imaginative leap of thinking 13:31.118 --> 13:33.488 what are the kinds of conditions, 13:33.490 --> 13:38.420 if you live in these places, that facilitate the spread of 13:38.422 --> 13:39.722 tuberculosis? 13:39.720 --> 13:48.870 Again, this is from Jacob Riis, a tenement in New York City. 13:48.870 --> 13:57.000 Here we see the conditions in which people were sleeping. 13:57.000 --> 14:02.260 This is what was called seven-cent lodgings in an 14:02.264 --> 14:05.234 unhappy street, Pell Street, 14:05.225 --> 14:07.525 in New York City. 14:07.528 --> 14:12.128 And you can see how tuberculosis would thrive in 14:12.129 --> 14:14.379 conditions like this. 14:14.379 --> 14:19.069 But let's also remember that tuberculosis also thrived 14:19.067 --> 14:21.897 because of conditions at work. 14:21.899 --> 14:26.659 And here's a sweatshop in the Garment District in New York 14:26.663 --> 14:28.923 City, again in the 1890s. 14:28.919 --> 14:32.739 Or here again another picture. 14:32.740 --> 14:35.460 I think you get the point. 14:35.460 --> 14:38.750 Remember too that prison populations, 14:38.750 --> 14:43.020 then and now, have been seriously affected 14:43.024 --> 14:47.314 with consumption, because the inmates there have 14:47.312 --> 14:51.132 often lived in conditions like those of tenements, 14:51.129 --> 14:55.069 with poor ventilation or lighting, pervasive damp, 14:55.070 --> 14:57.880 overcrowding, inadequate diet, 14:57.876 --> 14:59.616 poor sanitation. 14:59.620 --> 15:04.520 In conditions like that, tuberculosis runs riot. 15:04.519 --> 15:08.659 Indeed, the New York Times reported, 15:08.658 --> 15:14.278 in 1908, that it was a lie when judges sentenced convicted 15:14.275 --> 15:16.735 felons to hard labor. 15:16.740 --> 15:22.040 The truth, the paper reported, was that the sentence should be 15:22.037 --> 15:26.637 labeled "to hard labor and tuberculosis." 15:26.639 --> 15:30.119 In an inspection in 1905, the New York State 15:30.120 --> 15:34.570 Superintendent of Prisons declared that Sing Sing Prison 15:34.572 --> 15:38.062 in particular-- and here I'm quoting from the 15:38.062 --> 15:41.162 Superintendent of Prisons of New York State-- 15:41.158 --> 15:45.538 he called it "a hotbed for the culture and spread of 15:45.538 --> 15:49.478 tuberculosis, that should be abandoned as 15:49.476 --> 15:52.856 unfit for human habitation." 15:52.860 --> 15:57.080 Well, even if a person is infected, as I said, 15:57.080 --> 16:02.620 in the vast majority of people the immune system of the body 16:02.615 --> 16:04.955 contains the disease. 16:04.960 --> 16:09.660 In the nineteenth century, say in Paris or Le Havre, 16:09.658 --> 16:14.298 probably New York City as well, it's estimated that virtually 16:14.301 --> 16:18.011 every inhabitant had encountered Mycobacterium 16:18.014 --> 16:22.954 tuberculosis; but most remained asymptomatic 16:22.946 --> 16:25.146 and non-infectious. 16:25.149 --> 16:31.169 An active infection was promoted by a compromised immune 16:31.173 --> 16:34.533 system; let's say perhaps heredity, 16:34.525 --> 16:39.075 alcoholism, malnutrition, drug abuse, the presence of 16:39.082 --> 16:43.642 concurrent infections that are immunosuppressive. 16:43.639 --> 16:48.139 In our own times, one can think of malaria, 16:48.142 --> 16:53.292 AIDS or diabetes as forming a good substratum for 16:53.287 --> 16:55.107 tuberculosis. 16:55.110 --> 16:58.370 What are the symptoms of TB? 16:58.370 --> 17:01.290 Well, it's extremely variable. 17:01.288 --> 17:04.458 One of the mysteries of medicine, in fact, 17:04.457 --> 17:08.317 is the course of tuberculosis in the human body. 17:08.318 --> 17:12.478 It can be fulminant and lead to death in months. 17:12.480 --> 17:17.760 This is often called galloping consumption, at the time, 17:17.755 --> 17:20.245 or miliary tuberculosis. 17:20.250 --> 17:23.250 Alternatively, there can be an onset of 17:23.250 --> 17:26.410 symptoms, followed by recovery or 17:26.406 --> 17:31.646 remission, and then a relapse, and instead of leading to early 17:31.650 --> 17:34.210 death, it can lead to a long, 17:34.205 --> 17:38.885 chronic illness, often punctuated by prolonged 17:38.894 --> 17:43.534 remissions and equally mysterious relapses. 17:43.529 --> 17:48.659 Before the age of antibiotics, some eighty-percent of cases 17:48.656 --> 17:54.506 were deemed to end fatally, but in a time span that varied 17:54.509 --> 17:58.739 from up to fifteen, twenty years. 17:58.740 --> 18:03.420 And in every age there were spontaneous cures, 18:03.420 --> 18:05.500 or apparent cures. 18:05.500 --> 18:09.940 Let's look at two opposite extremes, two famous cases, 18:09.935 --> 18:14.195 the medical careers of two famous nineteenth-century 18:14.204 --> 18:15.884 British writers. 18:15.880 --> 18:22.880 The first is John Keats, who lived from 1795 until his 18:22.884 --> 18:27.384 death from tuberculosis in 1821. 18:27.380 --> 18:32.080 Note 1821; because he fell ill in February 18:32.084 --> 18:36.934 1820, and died the next year, at the age of twenty-six, 18:36.934 --> 18:39.634 from galloping consumption. 18:39.630 --> 18:43.080 Keats, in fact, became an icon of the 18:43.082 --> 18:48.552 relationship of tuberculosis to the arts and to genius. 18:48.548 --> 18:54.178 An entire century was familiar with the fact that he contracted 18:54.181 --> 18:58.361 the disease while tending his dying brother; 18:58.358 --> 19:03.368 that he made a desperate departure from Britain to Rome 19:03.368 --> 19:06.348 in search of health; and it knows, 19:06.353 --> 19:09.473 the world knew, at the time of his death and 19:09.474 --> 19:13.174 burial there, after a final period that was 19:13.165 --> 19:18.075 widely and romantically regarded as his most productive and 19:18.077 --> 19:19.177 brilliant. 19:19.180 --> 19:24.540 His life was described by romantic writers as that of a 19:24.541 --> 19:29.211 meteor, a comet, or a candle that rapidly burned 19:29.210 --> 19:30.700 itself out. 19:30.700 --> 19:35.330 And this became a focal point--and Keats himself did-- 19:35.328 --> 19:39.208 for the way this disease was construed or socially 19:39.211 --> 19:44.201 constructed in the middle of the nineteenth century as a disease 19:44.201 --> 19:45.311 of genius. 19:45.308 --> 19:50.428 It was considered to be a disease of sensibility and 19:50.432 --> 19:51.942 civilization. 19:51.940 --> 19:55.790 Let's look at the disease of a different person, 19:55.790 --> 19:57.840 whom you all know well. 19:57.838 --> 20:05.498 This is Robert Louis Stevenson, who lived from 1850 to 1894. 20:05.500 --> 20:09.490 This is a picture of him in about 1890. 20:09.490 --> 20:14.690 Stevenson, unlike Keats, battled tuberculosis for 20:14.686 --> 20:15.766 decades. 20:15.769 --> 20:20.539 He went in and out of health spas and sanatoriums. 20:20.538 --> 20:25.088 But he led a long and productive life that was ended, 20:25.093 --> 20:28.773 in fact ironically, not by tuberculosis but 20:28.769 --> 20:30.959 probably by a stroke. 20:30.960 --> 20:36.470 Now, in the nineteenth century, physicians regarded the course 20:36.472 --> 20:41.172 of pulmonary disease as passing through three stages, 20:41.172 --> 20:42.892 as they saw it. 20:42.890 --> 20:47.520 But remember though, before the tuberculin skin test 20:47.520 --> 20:50.790 and the development of radiology, 20:50.788 --> 20:55.208 tuberculosis was difficult to diagnose, 20:55.210 --> 21:00.790 as the symptoms mimicked those of other common diseases. 21:00.788 --> 21:05.498 And even if the diagnosis was accurate, one stage merged 21:05.497 --> 21:07.977 imperceptibly into another. 21:07.980 --> 21:11.430 But for nineteenth century physicians, there was still this 21:11.434 --> 21:12.274 distinction. 21:12.269 --> 21:15.699 The first stage, as they described it, 21:15.702 --> 21:20.432 was marked by a persistent cough, some difficulty in 21:20.434 --> 21:24.244 breathing, especially after exercise. 21:24.240 --> 21:27.550 The patient would sweat profusely. 21:27.548 --> 21:32.258 There would be an elevated pulse, pain in the chest and 21:32.256 --> 21:34.926 shoulders, general lassitude, 21:34.926 --> 21:39.986 a loss of weight, pallor, declining performance 21:39.994 --> 21:42.614 at work or at school. 21:42.608 --> 21:47.508 Then came a second stage when the cough became tormenting and 21:47.506 --> 21:52.316 frequent, and the patient would begin to cough up a greenish 21:52.321 --> 21:53.221 phlegm. 21:53.220 --> 21:57.290 He or she would experience intermittent fevers, 21:57.291 --> 22:01.451 spiking twice daily, with copious sweating and a 22:01.452 --> 22:02.872 rapid pulse. 22:02.868 --> 22:06.768 The patient would suffer from severe fatigability, 22:06.771 --> 22:11.471 from hoarseness that made it difficult and painful to eat or 22:11.470 --> 22:13.780 to speak above a whisper. 22:13.778 --> 22:18.768 There would be extreme shortness of breath on exertion, 22:18.769 --> 22:21.819 pain in the joints of the body. 22:21.818 --> 22:26.388 Then came the third stage of advanced tuberculosis, 22:26.387 --> 22:31.507 which gave the most common nineteenth-century name to the 22:31.505 --> 22:35.925 disease: consumption; that is, a frightening 22:35.931 --> 22:41.381 emaciation in which the body wasted away, or seemed to be 22:41.382 --> 22:42.552 consumed. 22:42.548 --> 22:45.978 The face would be hollow, the complexion pale. 22:45.980 --> 22:50.280 Perhaps this was one of the reasons that it was called the 22:50.278 --> 22:51.408 white plague. 22:51.410 --> 22:54.550 The eyes would be sunken in their sockets, 22:54.554 --> 22:57.934 and a patient could easily look like this. 22:57.930 --> 23:03.430 This is a picture of a consumptive patient in 1892. 23:03.430 --> 23:06.670 The cough now seemed like a death rattle, 23:06.672 --> 23:09.592 and the patient would cough blood. 23:09.588 --> 23:12.858 There would be constant pain in the joints. 23:12.859 --> 23:14.709 The legs would be swollen. 23:14.710 --> 23:18.610 There would be fever, often uncontrollable diarrhea, 23:18.608 --> 23:21.208 and extreme shortness of breath. 23:21.210 --> 23:25.080 At that point, the diagnosis was certain. 23:25.078 --> 23:28.798 But at this advanced stage death was imminent, 23:28.798 --> 23:32.268 and its form was unpleasant and painful; 23:32.269 --> 23:35.779 often asphyxia, as the patient virtually 23:35.784 --> 23:39.754 drowned on the phlegm in his or her lungs. 23:39.750 --> 23:43.800 Or there could be a sudden and unstoppable hemorrhage, 23:43.799 --> 23:47.319 with blood rushing from the mouth and nostrils, 23:47.315 --> 23:50.215 and the patient again suffocating. 23:50.220 --> 23:53.460 Well, what was it that happened to the lungs? 23:53.460 --> 24:00.770 Here's a modern x-ray slide of a TB patient's lungs. 24:00.769 --> 24:07.429 And let's look behind the x-ray at pictures of the lungs. 24:07.430 --> 24:15.150 Here is a set of healthy lungs, hopefully like all of yours. 24:15.150 --> 24:18.970 And then I'd like to take you through the drawings and 24:18.973 --> 24:23.163 pictures of the process called cavitation in the lungs, 24:23.160 --> 24:27.260 and the way in which the Mycobacterium 24:27.260 --> 24:32.490 tuberculosis consumes the respiratory organs. 24:32.490 --> 24:35.450 This is a famous drawing by Ren� Laennec, 24:35.450 --> 24:38.460 you know of the Paris School of Medicine, 24:38.460 --> 24:42.640 who was a tuberculosis authority, and he did this 24:42.637 --> 24:47.337 drawing of the onset of the cavitation in the lungs. 24:47.339 --> 24:55.739 Let's look at a picture of it. 24:55.740 --> 25:00.680 This is the process of necrosis at work in the tissues, 25:00.680 --> 25:04.870 and the end result would be the destruction of the lungs, 25:04.868 --> 25:10.138 which would look more or less like that. 25:10.140 --> 25:17.630 So, this was an enormously painful, horrible and unpleasant 25:17.627 --> 25:18.917 disease. 25:18.920 --> 25:24.050 And I want to argue that there are two great eras in the modern 25:24.049 --> 25:29.019 history of tuberculosis in which the disease was conceived or 25:29.016 --> 25:35.066 thought of quite differently, and without much relationship 25:35.065 --> 25:40.305 to the reality of the quality of the symptoms. 25:40.308 --> 25:45.128 The two periods are divided by the watershed of the germ theory 25:45.131 --> 25:49.451 of disease, established by Robert Koch from 25:49.452 --> 25:52.522 about 1882, and slowly then accepted 25:52.519 --> 25:55.299 thereafter by the medical profession, 25:55.299 --> 25:58.949 and educated society as a whole; not instantly, 25:58.954 --> 26:01.944 but in the decades that follow. 26:01.940 --> 26:06.490 I'd like to call the first era the era of consumption, 26:06.490 --> 26:10.440 or perhaps the romantic era of tuberculosis. 26:10.440 --> 26:15.380 Let's define it from the end of the eighteenth century to the 26:15.380 --> 26:19.910 middle, to about the time of Robert Koch's discovery. 26:19.910 --> 26:25.440 It was jolted first by, in the 1860s and '70s, 26:25.440 --> 26:28.150 by the work of Jean-Antoine Villemin, 26:28.150 --> 26:33.400 in France, who first convincingly proposed the idea 26:33.395 --> 26:36.015 that TB was contagious. 26:36.019 --> 26:41.009 And then the romantic era clearly came to an end with the 26:41.009 --> 26:45.359 work of Robert Koch, when society accepts this new 26:45.361 --> 26:50.221 interpretation, and the word consumption begins 26:50.224 --> 26:53.404 to fade from popular usage. 26:53.400 --> 26:57.450 Thomas Mann's great book, The Magic Mountain, 26:57.454 --> 27:01.514 is perhaps the last great artistic expression of the 27:01.510 --> 27:05.090 consumptive era and its susceptibilities. 27:05.088 --> 27:10.688 Now, what was the idea behind the romantic or consumptive 27:10.690 --> 27:11.590 theory? 27:11.588 --> 27:15.138 Its most authoritative formulation was by the great 27:15.144 --> 27:19.204 authority of the Paris School of Medicine, Ren� Laennec, 27:19.195 --> 27:23.305 whose drawing you just saw; the man who invented the 27:23.313 --> 27:27.703 stethoscope and spent his life listening to the lungs of 27:27.696 --> 27:29.686 tuberculosis patients. 27:29.690 --> 27:35.580 Laennec talked about what he called the essentialist theory. 27:35.578 --> 27:39.728 Ironically, given the opposition of the Paris School 27:39.729 --> 27:42.739 to Galen and humoralist teachings, 27:42.740 --> 27:48.860 we could see essentialism as actually a form of humoralism 27:48.858 --> 27:52.868 revived, a kind of anti-contagionism in 27:52.873 --> 27:54.293 classic dress. 27:54.289 --> 27:56.729 Now, note the irony. 27:56.730 --> 28:00.990 Your friend Ackerknecht--that is, the historian of medicine-- 28:00.990 --> 28:03.450 observed dryly, "After all, 28:03.450 --> 28:07.100 things have to be explained somehow." 28:07.098 --> 28:12.468 Well, TB was explained primarily by internal causes, 28:12.470 --> 28:17.420 due to the inherited essence of the patients; 28:17.420 --> 28:22.460 his or her constitution, or in Laennec's jargon, 28:22.460 --> 28:27.070 the patient's diathesis, which caused him or her to be 28:27.074 --> 28:31.784 susceptible to the immediate factors that triggered the 28:31.775 --> 28:33.425 actual illness. 28:33.430 --> 28:39.730 So, your diathesis was an inborn, inherited defect. 28:39.730 --> 28:45.390 Precipiting or immediate causes supervened, and these were 28:45.388 --> 28:50.948 thought to be some irregularity in the patient's life. 28:50.950 --> 28:55.890 Very important in the literature were alcoholism and 28:55.890 --> 28:57.440 sexual excess. 28:57.440 --> 29:03.670 Laennec postulated that two sorts of issues were important 29:03.674 --> 29:04.664 to him. 29:04.660 --> 29:10.620 One were what he called les passions tristes: 29:10.621 --> 29:15.761 melancholy, sorrow, despair, and again sexual 29:15.763 --> 29:17.053 excess. 29:17.048 --> 29:22.038 The loss of bodily fluids was thought to weaken the body and 29:22.038 --> 29:23.558 lead to illness. 29:23.558 --> 29:28.388 But both were almost an aspect of an individual's fate, 29:28.390 --> 29:30.180 his or her nature. 29:30.180 --> 29:33.140 So, consumption, unlike the other great epidemic 29:33.141 --> 29:35.411 killer of the nineteenth century-- 29:35.410 --> 29:40.190 that is, cholera--was not thought to be contagious but 29:40.186 --> 29:43.666 hereditary, and therefore its victims 29:43.665 --> 29:47.475 weren't feared or thought to be dangerous. 29:47.480 --> 29:52.910 And tuberculosis was a slow killer, not a cause of sudden 29:52.913 --> 29:53.693 death. 29:53.690 --> 29:57.290 And its symptoms, by the canons of the day, 29:57.286 --> 30:01.646 were deemed to be respectable, and not thought to be 30:01.653 --> 30:05.853 disgusting or a source of unbearable torment. 30:05.849 --> 30:08.909 And death was private; unlike cholera, 30:08.906 --> 30:10.996 not a public spectacle. 30:11.000 --> 30:14.080 Furthermore, tuberculosis wasn't so 30:14.082 --> 30:19.252 frightening because it was also an endemic disease and was 30:19.250 --> 30:21.790 ever-present in society. 30:21.788 --> 30:26.728 So, the effects on society were not at all like those of Asiatic 30:26.734 --> 30:27.524 cholera. 30:27.519 --> 30:32.139 We mustn't think of diseases as interchangeable causes of death 30:32.135 --> 30:36.525 that have the same effects on the societies they afflict. 30:36.529 --> 30:40.709 Tuberculosis didn't lead to terror, hysteria, 30:40.710 --> 30:44.890 xenophobia, revolt, and in its first phase it 30:44.890 --> 30:49.830 didn't lead to stigmatization, but its opposite. 30:49.828 --> 30:54.478 Patients with tuberculosis were thought to be glamorous, 30:54.481 --> 30:55.921 sexy, and chic. 30:55.920 --> 31:00.390 They were blameless, as it was their hereditary that 31:00.391 --> 31:01.971 was responsible. 31:01.970 --> 31:05.410 And there weren't outbursts of religiosity. 31:05.410 --> 31:10.210 There was a recognition that, in fact, large numbers of the 31:10.211 --> 31:13.691 social elite fell victim to the disease. 31:13.690 --> 31:16.480 There was no poisoning frenzy. 31:16.480 --> 31:22.430 This disease was too slow, too unrelated to digestion, 31:22.430 --> 31:26.640 too associated with the powerful, as well as the poor, 31:26.640 --> 31:31.630 and it was true that doctors and officials paid their tribute 31:31.634 --> 31:33.054 to the disease. 31:33.048 --> 31:37.678 But it did have major social effects, and let's think about 31:37.682 --> 31:39.682 what some of them were. 31:39.680 --> 31:45.760 A first was the widespread experience of patients. 31:45.759 --> 31:49.889 This is the career of invalidism. 31:49.890 --> 31:54.510 Tuberculosis, after diagnosis, 31:54.509 --> 31:59.129 became a lifetime's career. 31:59.130 --> 32:04.340 The rest of one's life, after receiving diagnosis, 32:04.344 --> 32:07.754 was unknown and unpredictable. 32:07.750 --> 32:12.470 And this would affect every possible decision: 32:12.473 --> 32:17.113 career choices; whether to marry and have a 32:17.106 --> 32:23.536 family, whether to place one's normal responsibilities on hold 32:23.540 --> 32:28.920 and to devote life to seeking to recover health. 32:28.920 --> 32:34.150 And, so, the sufferers tended to undertake a new and 32:34.148 --> 32:39.768 all-consuming occupation, restoring health and learning 32:39.770 --> 32:44.420 to accept what would probably be an early death. 32:44.420 --> 32:47.340 Let's think, for example, 32:47.338 --> 32:52.568 of Anton Chekhov, who's the man in the left, 32:52.570 --> 32:56.830 pictured here with Leo Tolstoy. 32:56.828 --> 33:01.208 Now, Chekhov, who lived from 1860 to 1904, 33:01.213 --> 33:04.853 was a sufferer from consumption. 33:04.848 --> 33:10.318 He was forced to abandon his own career, and his actress wife 33:10.315 --> 33:15.775 in Moscow, in the attempt to restore his shattered health. 33:15.778 --> 33:20.948 To do so, he went to the mild climate of the Crimea. 33:20.950 --> 33:26.580 His plays were all written in the period of his illness, 33:26.576 --> 33:32.406 and all subtly have invalidism as a hidden but unmentioned 33:32.406 --> 33:33.426 theme. 33:33.430 --> 33:38.290 The protagonists in Chekhov's plays, not by chance, 33:38.292 --> 33:40.922 seem oddly unable to act. 33:40.920 --> 33:46.710 They seem to be waiting and waiting for events beyond their 33:46.711 --> 33:48.711 control to unfold. 33:48.710 --> 33:52.850 The middle classes tended to go off to what was called 33:52.846 --> 33:57.006 "taking the cure"; that is, they traveled--in 33:57.009 --> 34:00.929 Europe, they would go to a climate that was thought to be 34:00.930 --> 34:03.770 favorable; spas and health resorts in 34:03.770 --> 34:06.600 southern Europe, on the French Riviera, 34:06.595 --> 34:07.705 or in Italy. 34:07.710 --> 34:10.420 Those were favorite destinations. 34:10.420 --> 34:14.510 And the list of distinguished travelers is lengthy. 34:14.510 --> 34:17.180 Keats and Shelley went to Rome. 34:17.179 --> 34:19.629 Tobias Smollett went to Nice. 34:19.630 --> 34:21.770 The Brownings went to Florence. 34:21.769 --> 34:24.029 Chopin went to Majorca. 34:24.030 --> 34:27.350 Paul Ehrlich went to Egypt. 34:27.349 --> 34:30.109 But this was also true in our own country. 34:30.110 --> 34:33.800 In the United States, people took sea journeys to 34:33.804 --> 34:37.584 recover their health, or they traveled to the west 34:37.576 --> 34:39.266 and the southwest. 34:39.268 --> 34:44.308 And here the famous frontier thesis in American history has 34:44.307 --> 34:46.217 yet another meaning. 34:46.219 --> 34:50.519 Health seekers formed a substantial current-- 34:50.518 --> 34:54.398 that is, of a movement west--and turned into a 34:54.400 --> 34:59.000 large-scale movement, with the availability of the 34:59.000 --> 35:01.260 railroad from the 1870s. 35:01.260 --> 35:07.830 Colorado Springs and Pasadena are examples of communities that 35:07.833 --> 35:11.823 were founded by, and for, tuberculosis 35:11.820 --> 35:13.330 sufferers. 35:13.329 --> 35:16.409 Also popular were other destinations; 35:16.409 --> 35:19.369 Florida and the Caribbean. 35:19.369 --> 35:22.739 And the cure became a kind of industry. 35:22.739 --> 35:27.229 It was stimulated by a flood of medical books; 35:27.230 --> 35:31.680 by rumor and anecdote; by brochures prepared by 35:31.677 --> 35:35.657 interested parties, such as the railroad companies. 35:35.659 --> 35:42.609 There were other exotic but more affordable ways of seeking 35:42.610 --> 35:43.930 the cure. 35:43.929 --> 35:48.759 One was altitude therapy, in which you'd go up high in a 35:48.759 --> 35:50.339 hot-air balloon. 35:50.340 --> 35:53.630 More commonly, people moved outdoors simply 35:53.630 --> 35:55.120 where they lived. 35:55.119 --> 35:58.159 In New York City, at the turn of the century, 35:58.159 --> 36:03.519 the buildings were dotted with people who'd moved to live in 36:03.519 --> 36:08.699 tents on the roofs and porches of apartment buildings, 36:08.699 --> 36:12.319 or in their backyards, if they had them. 36:12.320 --> 36:16.680 Let me remind you of Professor Irving Fisher, 36:16.679 --> 36:21.139 of Yale University, who in 1907 promoted health by 36:21.139 --> 36:26.599 inventing a tent that he claimed was perfectly ventilated for 36:26.603 --> 36:30.703 those who took to the out of doors life, 36:30.699 --> 36:36.199 and he wanted his tent to make outdoor living affordable for 36:36.195 --> 36:37.215 the poor. 36:37.219 --> 36:41.769 He himself was a consumptive, but he regained his health 36:41.768 --> 36:46.318 after living out of doors, and he aimed to make the cure 36:46.318 --> 36:48.468 universally available. 36:48.469 --> 36:50.259 If you read the New York Times, 36:50.260 --> 36:54.600 you would see there were people who moved not only to tents, 36:54.599 --> 36:59.289 but also to tree houses that they constructed in their yards; 36:59.289 --> 37:02.979 an example being Charles Battersby of Wrentham, 37:02.980 --> 37:07.150 Massachusetts, a consumptive who constructed a 37:07.150 --> 37:13.080 house between two adjoining pine trees and moved into it fulltime 37:13.079 --> 37:15.489 in the winter of 1906. 37:15.489 --> 37:19.859 Who knows to what extent the travels of people were also a 37:19.855 --> 37:24.445 means to escape the regimens that if they stayed at home, 37:24.449 --> 37:28.969 their physicians would have subjected them to at home? 37:28.969 --> 37:33.669 The treatments weren't especially enjoyable. 37:33.670 --> 37:39.920 There was bleeding and cupping, to release the noxious agents. 37:39.920 --> 37:42.880 There were direct applications to the lesions; 37:42.880 --> 37:47.030 poultices, ointments, infusions. 37:47.030 --> 37:49.650 There was also the spray therapy; 37:49.650 --> 37:54.510 that is, inhalations in which the doctors were attempting to 37:54.510 --> 37:59.620 attack the disease at its seat, as you inhaled gas mixtures; 37:59.619 --> 38:05.879 creosote and carbolic acid, had a large vogue in these 38:05.882 --> 38:07.302 centuries. 38:07.300 --> 38:11.110 Well, what about the effectiveness of the travels? 38:11.110 --> 38:15.560 In some cases, it's probably safe to say that 38:15.556 --> 38:18.586 the travels were beneficial. 38:18.590 --> 38:23.840 For pulmonary tuberculosis, it probably did help to escape 38:23.842 --> 38:27.532 the urban smog of a place like London. 38:27.530 --> 38:31.220 For Lupus vulgaris, the disease of the skin, 38:31.224 --> 38:33.964 sunlight is known to be beneficial. 38:33.960 --> 38:37.790 And it was probably beneficial just to have hope, 38:37.791 --> 38:42.341 and to have the belief that you could do something to help 38:42.342 --> 38:46.002 yourself; that probably did more good 38:46.001 --> 38:47.071 than harm. 38:47.070 --> 38:51.600 Tuberculosis also clearly had economic and demographic 38:51.603 --> 38:52.463 effects. 38:52.460 --> 38:56.200 Tuberculosis was the greatest killer of the young, 38:56.201 --> 38:59.331 at the time, and it inevitably limited the 38:59.331 --> 39:01.241 growth of population. 39:01.239 --> 39:06.539 It limited the expansion of the economy and caused widespread 39:06.536 --> 39:07.416 poverty. 39:07.420 --> 39:13.770 There was a new awareness and sensitivity to this death, 39:13.766 --> 39:15.956 with romanticism. 39:15.960 --> 39:19.010 Tuberculosis, I want to say, 39:19.014 --> 39:23.094 was not the cause of romanticism, 39:23.090 --> 39:28.500 but it is true that romantic literature, 39:28.500 --> 39:33.340 and the arts, did fit some qualities about 39:33.338 --> 39:35.108 tuberculosis. 39:35.110 --> 39:40.350 That is, romanticism stressed the transience of youth, 39:40.347 --> 39:44.497 early death, melancholy, life as ephemeral, 39:44.498 --> 39:48.548 the importance of autumn as a symbol; 39:48.550 --> 39:53.900 no longer now a symbol of the harvest, but as a time of 39:53.904 --> 39:59.164 falling leaves and dying flowers, as death sets in. 39:59.159 --> 40:02.749 Genius was part of it. 40:02.750 --> 40:06.980 The redemptive and ennobling idea of suffering, 40:06.978 --> 40:12.588 that releases the life of the soul, as the gross material body 40:12.588 --> 40:14.058 wastes away. 40:14.059 --> 40:18.669 And there was a poetic quality that was attributed to 40:18.670 --> 40:20.000 tuberculosis. 40:20.000 --> 40:25.880 It was said to release genius and creativity. 40:25.880 --> 40:30.630 One sees this portrayed in romantic works in the century. 40:30.630 --> 40:33.610 Emily Bront�, Wuthering Heights; 40:33.610 --> 40:34.470 Victor Hugo, Les 40:34.471 --> 40:41.091 Mis�rables; Alexandre Dumas, Henri Murger. 40:41.090 --> 40:44.580 Or romantic opera: Verdi's La Traviata, 40:44.583 --> 40:48.313 or Puccini's La Boh�me. 40:48.309 --> 40:51.709 Then I would argue that tuberculosis also--so, 40:51.706 --> 40:54.116 it had an effect, and the effect, 40:54.123 --> 40:57.223 the causal chain worked in both ways; 40:57.219 --> 41:00.019 an effect in promoting romanticism, 41:00.018 --> 41:04.518 and romanticism in turn promoted a certain understanding 41:04.516 --> 41:08.436 or social construction of the disease itself-- 41:08.440 --> 41:11.620 had a major impact then on literature, 41:11.619 --> 41:15.109 and was portrayed often in literature, 41:15.110 --> 41:18.380 and indeed in the opera. 41:18.380 --> 41:23.950 Tuberculosis also had an effect on gender issues. 41:23.949 --> 41:29.939 I would argue that it helped to promote a new idea of feminine 41:29.936 --> 41:32.486 beauty: thin, elongated; 41:32.489 --> 41:34.519 tubercular, in short. 41:34.519 --> 41:36.069 Pallor. 41:36.070 --> 41:39.480 At the time, white powders--not suntan oil, 41:39.483 --> 41:41.843 as today--were the fashion. 41:41.840 --> 41:44.950 Let me show you an example. 41:44.949 --> 41:49.069 This is a famous painting of a woman at the table, 41:49.070 --> 41:50.920 by Toulouse Lautrec. 41:50.920 --> 41:55.180 And you'll note that she looks extremely pallid, 41:55.184 --> 41:57.004 and is quite thin. 41:57.000 --> 42:01.910 But what I wanted to point out is what she has in front of her, 42:01.909 --> 42:07.769 which is a pot of rice powder that she puts on her face to 42:07.771 --> 42:11.681 imitate the pallor of a consumptive. 42:11.679 --> 42:15.499 One can see this also in the paintings of the 42:15.496 --> 42:19.136 pre-Raphaelites, whose favorite models were 42:19.139 --> 42:22.089 often women with tuberculosis. 42:22.090 --> 42:24.850 Elizabeth Siddal, for example, 42:24.847 --> 42:29.697 was a model for ten years, and then became the wife, 42:29.697 --> 42:33.977 of Dante Rossetti, and became also a model for 42:33.978 --> 42:35.308 Millais. 42:35.309 --> 42:38.839 Jane Burden became the model, and also the wife, 42:38.844 --> 42:40.354 of William Morris. 42:40.349 --> 42:44.339 And one can see some of the--you can see the 42:44.338 --> 42:53.908 elongated--this is Mariana; this is the Beata Beatrix. 42:53.909 --> 42:57.749 In any case then, consumption was a fatal, 42:57.753 --> 43:02.443 debilitating and excruciatingly painful disease. 43:02.440 --> 43:07.620 But paradoxically then it was given positive associations in 43:07.617 --> 43:11.037 the way it was described at the time. 43:11.039 --> 43:15.239 Tuberculosis was said to make the body beautiful, 43:15.239 --> 43:20.879 to make a person spiritual by wasting away the gross flesh, 43:20.880 --> 43:25.750 and it was said to enhance creativity and genius. 43:25.750 --> 43:29.530 How can this be explained? 43:29.530 --> 43:33.660 Well, in the United States, tuberculosis was also thought 43:33.661 --> 43:37.861 to be the white plague, partly because it was popularly 43:37.864 --> 43:42.074 regarded as a disease that affected the white race and not 43:42.068 --> 43:45.098 African-Americans, who were thought to have a 43:45.099 --> 43:47.859 different affliction in the middle of the nineteenth 43:47.862 --> 43:48.462 century. 43:48.460 --> 43:51.190 Tellingly, it was called "the white man's 43:51.186 --> 43:54.336 plague" and "the white man's scourge," 43:54.338 --> 43:55.548 in this country. 43:55.550 --> 43:58.410 And in Europe, it wasn't associated in the 43:58.409 --> 44:01.269 popular mind with the working classes, 44:01.268 --> 44:05.388 and people remembered that aristocrats and artistic 44:05.389 --> 44:08.189 celebrities often contracted it. 44:08.190 --> 44:12.200 You can see the power of what we might call advertising, 44:12.199 --> 44:15.169 the endless stream of novels, poems, 44:15.170 --> 44:20.510 operas, that extolled the beauty and sensitivity of those 44:20.514 --> 44:21.664 afflicted. 44:21.659 --> 44:24.759 In addition, recalling what we said about 44:24.762 --> 44:28.742 bubonic plague, tuberculosis did not evoke the 44:28.744 --> 44:32.714 fear of mors repentina: sudden death, 44:32.710 --> 44:37.880 so dreaded with bubonic plague or Asiatic cholera. 44:37.880 --> 44:41.250 With consumption, there was no danger that a 44:41.250 --> 44:46.030 person would be caught unaware and not even have time to write 44:46.032 --> 44:47.602 his or her will. 44:47.599 --> 44:50.149 The disease was spiritual, in part, 44:50.150 --> 44:55.230 because it warned the sufferer of death in ample time to work 44:55.231 --> 45:00.061 out one's relationship with God and with the community. 45:00.059 --> 45:03.369 There was also a simple matter of comparison. 45:03.369 --> 45:06.339 Consumption death, consumptive death, 45:06.340 --> 45:10.550 was perhaps construed as beautiful because pulmonary 45:10.550 --> 45:15.090 disease didn't disfigure in the manner of smallpox. 45:15.090 --> 45:19.650 Its symptoms weren't degrading, in the manner of Asiatic 45:19.650 --> 45:20.480 cholera. 45:20.480 --> 45:24.510 Well so to make the point, let's turn to a work that 45:24.514 --> 45:28.654 probably all of you know, the most influential, 45:28.652 --> 45:32.962 best-selling novel of the nineteenth century, 45:32.960 --> 45:37.690 which was Harriet Beecher Stowe, Uncle Tom's Cabin. 45:37.690 --> 45:42.200 You probably know very well that it was a religious novel, 45:42.199 --> 45:47.409 about social justice and God's way with man, 45:47.409 --> 45:52.669 that it was about Simon Legree and the horrors of slavery, 45:52.670 --> 45:55.590 and called for abolition. 45:55.590 --> 46:01.100 But you've probably forgotten that it was also a major 46:01.103 --> 46:05.263 tuberculosis novel, and that the heroine, 46:05.264 --> 46:10.054 the child Little Eva, dies of consumption. 46:10.050 --> 46:14.960 Let me remind you of how Harriet Beecher Stowe described 46:14.963 --> 46:16.753 approaching death. 46:16.750 --> 46:20.370 And she wrote: "For so bright and placid 46:20.369 --> 46:24.319 was the farewell voyage of the little spirit-- 46:24.320 --> 46:29.010 by such sweet and fragrant breezes was the small bark borne 46:29.005 --> 46:33.475 towards the heavenly shores-- -that it was impossible to 46:33.476 --> 46:36.196 realize that death was approaching. 46:36.199 --> 46:41.569 The child felt no pain, only a tranquil soft weakness, 46:41.567 --> 46:45.717 daily and almost insensibly increasing. 46:45.719 --> 46:49.779 And she was so beautiful, so loving, 46:49.780 --> 46:52.950 so trustful, so happy, that one could not 46:52.945 --> 46:57.925 resist the soothing influence of that air of innocence and peace 46:57.934 --> 47:01.264 that seemed to breathe all around her. 47:01.260 --> 47:04.840 Her father found a strange calm coming over him. 47:04.840 --> 47:07.730 It wasn't hope--that was impossible; 47:07.730 --> 47:11.240 it was not resignation; it was only a calm resting in 47:11.244 --> 47:14.874 the present that seemed so beautiful that he wished to 47:14.873 --> 47:16.383 think of no future. 47:16.380 --> 47:20.470 It was like that hush of spirit that we feel amid the bright, 47:20.469 --> 47:24.579 mild woods of autumn, when the bright hectic flush is 47:24.576 --> 47:28.436 on the trees, and the last lingering flowers 47:28.436 --> 47:31.986 by the brook; and we joy in it all the more, 47:31.987 --> 47:35.957 because we know that it will soon pass away." 47:35.960 --> 47:41.450 Now, I would argue that this bears little relationship to the 47:41.449 --> 47:47.489 actual extraordinary suffering of tuberculosis at the very end, 47:47.489 --> 47:52.969 and I think it makes a good way to have a transition from the 47:52.972 --> 47:58.822 consumptive era to what I would call the era of tuberculosis, 47:58.820 --> 48:01.960 when the way that disease, this disease, 48:01.960 --> 48:06.870 was constructed and understood changes radically. 48:06.869 --> 48:11.419 And this comes about after the germ theory of disease and the 48:11.416 --> 48:15.926 work of Robert Koch, when the disease was found not 48:15.934 --> 48:20.194 to be hereditary and due to one's diathesis, 48:20.190 --> 48:24.150 but to be a nasty, contagious disease, 48:24.150 --> 48:27.630 when sufferers became objects of fear, 48:27.630 --> 48:32.650 and stigma attached to them; when the glamour of consumption 48:32.652 --> 48:36.322 was stripped away, as was its association with 48:36.320 --> 48:40.630 feminine beauty, and male genius and poetry, 48:40.632 --> 48:46.282 and its appeal as a period of spirituality and sexuality 48:46.279 --> 48:47.819 disappeared. 48:47.820 --> 48:51.110 So, that's what I want to talk about next time, 48:51.112 --> 48:55.552 which is the movement from the era of consumption to the era of 48:55.552 --> 48:56.772 tuberculosis. 48:56.769 --> 49:01.999