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The history of tuberculosis encompasses the origins, evolution, and spread of tuberculosis (TB) throughout human history, as well as the development of medical understanding, treatments, and control methods for this ancient disease. Tuberculosis is an infectious disease caused by bacteria of the ''
Mycobacterium tuberculosis ''Mycobacterium tuberculosis'' (M. tb), also known as Koch's bacillus, is a species of pathogenic bacteria in the family Mycobacteriaceae and the causative agent of tuberculosis. First discovered in 1882 by Robert Koch, ''M. tuberculosis'' ha ...
'' complex (MTBC). Throughout history, tuberculosis has been known by differing names, including consumption, phthisis, and the White Plague. Paleopathological evidence finds tuberculosis in humans since at least the
Neolithic The Neolithic or New Stone Age (from Ancient Greek, Greek 'new' and 'stone') is an archaeological period, the final division of the Stone Age in Mesopotamia, Asia, Europe and Africa (c. 10,000 BCE to c. 2,000 BCE). It saw the Neolithic Revo ...
(approximately 10,000-11,000 years ago), with molecular studies suggesting a much earlier emergence and co-evolution with humans. Phylogenetic analyses indicate that the TB originated in Africa and evolved alongside human populations for tens of thousands of years. The disease spread globally through human migrations, adapting to different human populations and eventually developing into several distinct lineages with varying geographic distributions. While TB has affected humanity for millennia, it became particularly prevalent during industrialization when urban overcrowding aided transmission. The medical understanding of tuberculosis transformed in the 19th century with Robert Koch's 1882 identification of ''Mycobacterium tuberculosis'' as the causative
bacterium Bacteria (; : bacterium) are ubiquitous, mostly free-living organisms often consisting of one biological cell. They constitute a large domain of prokaryotic microorganisms. Typically a few micrometres in length, bacteria were among the ...
, followed by the development of
vaccines A vaccine is a biological preparation that provides active acquired immunity to a particular infectious or malignant disease. The safety and effectiveness of vaccines has been widely studied and verified. A vaccine typically contains an ag ...
and
antibiotic An antibiotic is a type of antimicrobial substance active against bacteria. It is the most important type of antibacterial agent for fighting pathogenic bacteria, bacterial infections, and antibiotic medications are widely used in the therapy ...
treatments in the mid-20th century.


Origins

The modern understanding of the evolutionary origins of ''Mycobacterium tuberculosis'' has been revolutionized by recent
genomic Genomics is an interdisciplinary field of molecular biology focusing on the structure, function, evolution, mapping, and editing of genomes. A genome is an organism's complete set of DNA, including all of its genes as well as its hierarchical, ...
and
phylogenetic In biology, phylogenetics () is the study of the evolutionary history of life using observable characteristics of organisms (or genes), which is known as phylogenetic inference. It infers the relationship among organisms based on empirical dat ...
research. Current evidence suggests that tuberculosis is an ancient human disease that co-evolved with human populations for tens of thousands of years, rather than a recent acquisition from domesticated animals during the Neolithic as previously believed. There has also been a claim of evidence of lesions characteristic of tuberculosis in a 500,000-year-old ''
Homo erectus ''Homo erectus'' ( ) is an extinction, extinct species of Homo, archaic human from the Pleistocene, spanning nearly 2 million years. It is the first human species to evolve a humanlike body plan and human gait, gait, to early expansions of h ...
'' fossil, although this finding is controversial.


Phylogenetic Evidence

Comprehensive phylogenetic analyses of the ''Mycobacterium tuberculosis'' complex (MTBC) demonstrate an African origin for the pathogen. Whole-genome sequencing of modern TB strains reveals that the bacteria emerged in Africa and followed human migration out of Africa. Research analyzing 259 global TB clinical strains suggests that tuberculosis arose roughly 70,000 years ago, expanding in two major waves: first around 67,000 years ago during human migration to South Asia, and again around 46,000 years ago during migrations to the Near East, Europe, and Asia. Within TB, researchers have identified multiple lineages (currently nine human-adapted lineages) associated with different geographical regions. These include Lineage 1 (East Africa, Philippines), Lineages 2-4 (Eurasia), Lineages 5-6 (West Africa), Lineage 7 (Ethiopia), Lineage 8 (East Africa), and Lineage 9 (East Africa). Animal-adapted lineages, including '' M. bovis'' which infects cattle, evolved from human strains rather than the reverse, contradicting earlier theories about TB's origins. The discovery of ''M. tuberculosis'' Lineage 8 strains in East Africa, which retain genetic features seen in more ancestral mycobacteria but absent in other TB lineages, provides evidence for the ancient African origin of tuberculosis.


Paleopathological Evidence

The oldest confirmed paleopathological evidence of human tuberculosis dates to the
Pre-Pottery Neolithic The Pre-Pottery Neolithic (PPN) represents the early Neolithic in the Near East, dating to years ago, (10000 – 6500 BCE).Richard, Suzanne ''Near Eastern archaeology'' Eisenbrauns; illustrated edition (1 Aug 2004) p.24/ref> It succeeds the ...
(10,000-11,000 years ago) in the Near East. Key early cases include remains from Dja'de el Mughara and Tell Aswad in Syria (8800-7600 BCE), Ain Ghazal in Jordan (7250 BCE), and
Atlit Yam Atlit Yam (Hebrew language, Hebrew: עתלית ים) is a submerged Pre-Pottery Neolithic, Pre Pottery Neolithic C (PPNC) archaeological site located 300–400 meters off the coast of Atlit (modern town), Atlit, Israel. Dating from the late 7th to ...
in Israel (6200-5500 BCE), where molecular analyses confirmed the presence of TB DNA. In Europe, the earliest confirmed cases come from the Early Neolithic Linear Pottery culture sites in Germany (5400-4800 BCE). A controversial finding reported in 2014 based on DNA from 1,000-year-old skeletons in Peru suggested that tuberculosis might have been transmitted to humans from seals, possibly originating only 6,000 years ago. However, subsequent research has challenged this interpretation. The Peruvian samples showed evidence of a TB strain related to ''M. pinnipedii'' (seal TB), but this represents a localized
zoonotic A zoonosis (; plural zoonoses) or zoonotic disease is an infectious disease of humans caused by a pathogen (an infectious agent, such as a virus, bacterium, parasite, fungi, or prion) that can jump from a non-human vertebrate to a human. When h ...
transfer specific to pre-colonial South America rather than the origin of human tuberculosis. These seal-derived strains infected coastal populations and spread inland but were eventually replaced by European strains of ''M. tuberculosis'' brought in by colonists. This finding represents an example of animal-to-human transmission, but does not contradict the evidence for much earlier human tuberculosis in Africa and Eurasia. The limited paleopathological evidence from the
Upper Paleolithic The Upper Paleolithic (or Upper Palaeolithic) is the third and last subdivision of the Paleolithic or Old Stone Age. Very broadly, it dates to between 50,000 and 12,000 years ago (the beginning of the Holocene), according to some theories ...
(40,000-10,000 years ago) despite its importance in TB evolution represents a paradox.This may be explained by the low population density of Paleolithic
hunter-gatherers A hunter-gatherer or forager is a human living in a community, or according to an ancestrally derived lifestyle, in which most or all food is obtained by foraging, that is, by gathering food from local naturally occurring sources, especially w ...
, which would have limited TB transmission and skeletal signs, or by limitations in identifying ancient tuberculosis.


Early Evolution

Genomic research indicate that the emergence and spread of tuberculosis were not linked to
animal domestication The domestication of vertebrates is the mutual relationship between vertebrate animals, including birds and mammals, and the humans who influence their care and reproduction. Charles Darwin recognized a small number of traits that made domestica ...
during the Neolithic, but rather to human population dynamics. The
Neolithic demographic transition The Neolithic demographic transition was a period of rapid population growth following the adoption of agriculture by prehistoric societies (the Neolithic Revolution). It was a demographic transition caused by an abrupt increase in birth rates due ...
(with increased population density and sedentism) aided tuberculosis transmission and allowed it to become more widespread, but long before this, the pathogen had already become adapted to humans. The
co-evolution In biology, coevolution occurs when two or more species reciprocally affect each other's evolution through the process of natural selection. The term sometimes is used for two traits in the same species affecting each other's evolution, as well a ...
between TB and humans is evidenced by the adaptation of different tuberculosis lineages to different human populations, reflecting geographical patterns of human migration and settlement. Genetic studies also show evidence of selection pressure exerted by tuberculosis on human populations, such as the changing frequency of TB susceptibility variants like TYK2 P1104A in Europeans over the past 2,000 years. Although relatively little is known about its frequency before the 19th century, its incidence is thought to have peaked between the end of the 18th century and the end of the 19th century. Over time, the various cultures of the world gave the illness different names: ''phthisis'' (Greek), ''consumptio'' (Latin), ''yaksma'' (India), and ''chaky oncay'' (Incan), each of which make reference to the "drying" or "consuming" effect of the illness,
cachexia Cachexia () is a syndrome that happens when people have certain illnesses, causing muscle loss that cannot be fully reversed with improved nutrition. It is most common in diseases like cancer, Heart failure, congestive heart failure, chronic o ...
. In the 19th century, TB's high mortality rate among young and middle-aged adults and the surge of
Romanticism Romanticism (also known as the Romantic movement or Romantic era) was an artistic and intellectual movement that originated in Europe towards the end of the 18th century. The purpose of the movement was to advocate for the importance of subjec ...
, which stressed feeling over reason, caused many to refer to the disease as the "romantic disease".


Tuberculosis in early civilization

In 2008, evidence for tuberculosis infection was discovered in human remains from the Neolithic era dating from 9,000 years ago, in
Atlit Yam Atlit Yam (Hebrew language, Hebrew: עתלית ים) is a submerged Pre-Pottery Neolithic, Pre Pottery Neolithic C (PPNC) archaeological site located 300–400 meters off the coast of Atlit (modern town), Atlit, Israel. Dating from the late 7th to ...
, a settlement in the eastern Mediterranean. This finding was confirmed by morphological and molecular methods; to date it is the oldest evidence of tuberculosis infection in humans. Evidence of the infection in humans was also found in a cemetery near Heidelberg, in the
Neolithic The Neolithic or New Stone Age (from Ancient Greek, Greek 'new' and 'stone') is an archaeological period, the final division of the Stone Age in Mesopotamia, Asia, Europe and Africa (c. 10,000 BCE to c. 2,000 BCE). It saw the Neolithic Revo ...
bone remains that show evidence of the type of angulation often seen with spinal tuberculosis. Some authors call tuberculosis the first disease known to mankind. Signs of the disease have also been found in Egyptian mummies dated between 3000 and 2400 BC. The most convincing case was found in the mummy of priest Nesperehen, discovered by Grebart in 1881, which featured evidence of spinal tuberculosis with the characteristic psoas abscesses. Similar features were discovered on other mummies like that of the priest Philoc and throughout the cemeteries of Thebes. It appears likely that
Akhenaten Akhenaten (pronounced ), also spelled Akhenaton or Echnaton ( ''ʾŪḫə-nə-yātəy'', , meaning 'Effective for the Aten'), was an ancient Egyptian pharaoh reigning or 1351–1334 BC, the tenth ruler of the Eighteenth Dynasty of Egypt, Eig ...
and his wife
Nefertiti Nefertiti () () was a queen of the Eighteenth Dynasty of Egypt, 18th Dynasty of Ancient Egypt, the Great Royal Wife, great royal wife of Pharaoh Akhenaten. Nefertiti and her husband were known for their radical overhaul of state religious poli ...
both died from tuberculosis, and evidence indicates that hospitals for tuberculosis existed in Egypt as early as 1500 BC. The
Ebers papyrus The Ebers Papyrus, also known as Papyrus Ebers, is an Egyptian medical papyrus of herbal knowledge dating to (the late Second Intermediate Period or early New Kingdom). Among the oldest and most important medical papyri of Ancient Egypt, it ...
, an important Egyptian medical treatise from around 1550 BC, describes a pulmonary consumption associated with the cervical lymph nodes. It recommended that it be treated with the surgical lancing of the cyst and the application of a ground mixture of acacia seyal, peas, fruits, animal blood, insect blood, honey and salt. The
Old Testament The Old Testament (OT) is the first division of the Christian biblical canon, which is based primarily upon the 24 books of the Hebrew Bible, or Tanakh, a collection of ancient religious Hebrew and occasionally Aramaic writings by the Isr ...
mentions a consumptive illness that would affect the Jewish people if they stray from God. It is listed in the section of curses given before they enter the land of Canaan.


The East


Ancient India

The first references to tuberculosis in non-European civilization is found in the
Veda FIle:Atharva-Veda samhita page 471 illustration.png, upright=1.2, The Vedas are ancient Sanskrit texts of Hinduism. Above: A page from the ''Atharvaveda''. The Vedas ( or ; ), sometimes collectively called the Veda, are a large body of relig ...
s. The oldest of them (
Rigveda The ''Rigveda'' or ''Rig Veda'' (, , from wikt:ऋच्, ऋच्, "praise" and wikt:वेद, वेद, "knowledge") is an ancient Indian Miscellany, collection of Vedic Sanskrit hymns (''sūktas''). It is one of the four sacred canoni ...
, 1500 BC) calls the disease ''yaksma''. The
Atharvaveda The Atharvaveda or Atharva Veda (, , from ''wikt:अथर्वन्, अथर्वन्'', "priest" and ''wikt:वेद, वेद'', "knowledge") or is the "knowledge storehouse of ''wikt:अथर्वन्, atharvans'', the proced ...
called it ''balasa''. It is in the Atharvaveda that the first description of scrofula was given. The ''
Sushruta Samhita The ''Sushruta Samhita'' (, ) is an ancient Sanskrit text on medicine and one of the most important such treatises on this subject to survive from the ancient world. The ''Compendium of Sushruta, Suśruta'' is one of the foundational texts of ...
'', compiled during the period ca. 200 BCE - 500 CE, recommended that the disease be treated with breast milk, various meats, alcohol and rest.Ghose 2003:214 The
Yajurveda The ''Yajurveda'' (, , from यजुस्, "worship", and वेद, "knowledge") is the Veda primarily of prose mantras for worship rituals.Michael Witzel (2003), "Vedas and Upaniṣads", in ''The Blackwell Companion to Hinduism'' (Edito ...
advised affected individuals to move to higher altitudes.


Ancient China

The
Classical Chinese Classical Chinese is the language in which the classics of Chinese literature were written, from . For millennia thereafter, the written Chinese used in these works was imitated and iterated upon by scholars in a form now called Literary ...
word ''lào'' "consumption; tuberculosis" was the common name in
traditional Chinese medicine Traditional Chinese medicine (TCM) is an alternative medicine, alternative medical practice drawn from traditional medicine in China. A large share of its claims are pseudoscientific, with the majority of treatments having no robust evidence ...
and ''fèijiéhé'' 肺結核 (lit. "lung knot kernel") "pulmonary tuberculosis" is the modern medical term. ''Lao'' is compounded in names like ''xulao'' 癆 with "empty; void", ''láobìng'' 癆 with "sickness", ''láozhài'' 癆 with " rchaicsickness", and ''feilao'' 癆 with "lungs". Zhang and Unschuld explain that the medical term ''xulao'' 虛癆 "depletion exhaustion" includes infectious and consumptive pathologies, such as ''laozhai'' 癆瘵 "exhaustion with consumption" or ''laozhaichong'' 癆瘵蟲 "exhaustion consumption bugs/worms". They retrospectively identify ''feilao'' 肺癆 "lung exhaustion" and infectious ''feilao chuanshi'' 肺癆傳尸 "lung exhaustion by corpse viltransmission as "consumption/tuberculosis". Describing foreign loanwords in early medical terminology, Zhang and Unschuld note the phonetic similarity between Chinese ''feixiao'' 肺消 (from
Old Chinese Old Chinese, also called Archaic Chinese in older works, is the oldest attested stage of Chinese language, Chinese, and the ancestor of all modern varieties of Chinese. The earliest examples of Chinese are divinatory inscriptions on oracle bones ...
''**pʰot-ssew'') "lung consumption" and ancient Greek '' phthisis'' "pulmonary tuberculosis". The ''
Huangdi Neijing ' (), literally the ''Inner Canon of the Yellow Emperor'' or ''Esoteric Scripture of the Yellow Emperor'', is an ancient Chinese medical text or group of texts that has been treated as a fundamental doctrinal source for Chinese medicine for mo ...
'' classic Chinese medical text ( – 260 CE), traditionally attributed to the mythical
Yellow Emperor The Yellow Emperor, also known as the Yellow Thearch, or Huangdi ( zh, t=黃帝, s=黄帝, first=t) in Chinese, is a mythical Chinese sovereign and culture hero included among the legendary Three Sovereigns and Five Emperors. He is revered as ...
, describes a disease believed to be tuberculosis, called ''xulao bing'' (虛癆病 "weak consumptive disease"), characterized by persistent cough, abnormal appearance, fever, a weak and fast pulse, chest obstructions, and shortness of breath. The ''Huangdi Neijing'' describes an incurable disease called ''huaifu'' 壞府 "bad palace", which commentators interpret as tuberculous. "As for a string which is cut, its sound is hoarse. As for wood which has become old, its leaves are shed. As for a disease which is in the depth f the body the sound it eneratesis hiccup. When a man has these three tates this is called 'destroyed palace'. Toxic drugs do not bring a cure; short needles cannot seize he disease Wang Bing's commentary explains that ''fu'' 府 "palace" stands for ''xiong'' 胸 "chest", and ''huai'' "destroy" implies "injure the palace and seize the disease". The ''Huangdi Neijing'' compiler Yang Shangshan notes, "The iseaseproposed here very much resembles tuberculosis ... Hence he textstates: poisonous drugs bring no cure; it cannot be seized with short needles." The ''
Shennong Bencaojing ''Shennong Bencaojing'' (also ''Classic of the Materia Medica'' or ''Shen-nong's Herbal Classics'' and ''Shen-nung Pen-tsao Ching''; ) is a Chinese book on agriculture and medicinal plants, traditionally attributed to Shennong. Researchers belie ...
'' pharmacopeia (–250 CE), attributed to the legendary inventor of agriculture
Shennong Shennong ( zh, c=神農, p=Shénnóng), variously translated as "Divine Farmer" or "Divine Husbandman", born , was a mythological Chinese ruler known as the first Yan Emperor who has become a deity in Chinese and Vietnamese folk religion. H ...
"Divine Farmer", also refers to tuberculosis The ''Zhouhou beiji fang'' 肘后备急方 "Handbook of Prescriptions for Emergencies", attributed to the Daoist scholar
Ge Hong Ge Hong (; b. 283 – d. 343 or 364), courtesy name Zhichuan (稚川), was a Chinese linguist, philosopher, physician, politician, and writer during the Eastern Jin dynasty. He was the author of '' Essays on Chinese Characters'', the '' Baopu ...
(263–420), uses the name of ''shizhu'' 尸疰 "corpse disease; tuberculosis" and describes the symptoms and contagion:
Song dynasty The Song dynasty ( ) was an Dynasties of China, imperial dynasty of China that ruled from 960 to 1279. The dynasty was founded by Emperor Taizu of Song, who usurped the throne of the Later Zhou dynasty and went on to conquer the rest of the Fiv ...
(920–1279) Daoist priest-doctors first recorded that tuberculosis, called ''shīzhài'' 尸瘵 (lit. "corpse disease") "disease which changes a living being into a corpse", was caused by a specific parasite or pathogen, centuries earlier than their contemporaries in other countries. The ''Duanchu shizhai pin'' 斷除尸瘵品 "On the Extermination of the Corpse Disease" is the 23rd chapter in Daoist collection ''Wushang xuanyuan santian Yutang dafa'' 無上玄元三天玉堂大法 "Great Rites of the Jade Hall of the Three Heavens of the Supreme Mysterious Origins" (''
Daozang The Daozang ( zh, c=道藏, p=Dàozàng, w=Tao Tsang) is a large canon of Taoist writings, consisting of around 1,500 texts that were seen as continuing traditions first embodied by the '' Daodejing'', '' Zhuangzi'', and '' Liezi''. The canon was ...
'' number 103). The text has a preface dated 1126, written by the Song dynasty
Zhengyi Dao Zhengyi Dao (), also known as the Way of Orthodox Unity, Teaching of the Orthodox Unity, and Branch of the Orthodox Unity is a Chinese Taoist movement that traditionally refers to the same Taoist lineage as the Way of the Five Pecks of Rice and ...
master Lu Shizhong 路時中, who founded the Yutang dafa 玉堂大法 tradition, but internal evidence reveals that the text could not have been written before 1158. This passage refers to the cause of TB in ancient medical terminology of ''jiuchong'' 九蟲 "Nine Worms" and '' gu'' 蠱 "supernatural agents causing disease", and '' qi''. The Nine Worms generically meant "bodily parasites; intestinal worms" and were associated with the ''sanshi'' 三尸 " Three Corpses" or ''sanchong'' 三蟲 "Three Worms", which were believed to be biospiritual parasites that live in the human body and seek to hasten their host's death. Daoist medical texts give different lists and descriptions of the Nine Worms. The ''Boji fang'' 博濟方 "Prescriptions for Universal Dispensation", collected by Wang Gun王袞 (fl. 1041), calls the supposed TB pathogen ''laochong'' 癆蟲 "tuberculosis worms". This ''Duanchu shizhai pin'' chapter (23/7b-8b) explains that the present Nine Worms does not refer to the intestinal ''weichong'' 胃蟲 "stomach worms", ''huichong'' 蛔蟲 "coiling worm;
roundworm The nematodes ( or ; ; ), roundworms or eelworms constitute the phylum Nematoda. Species in the phylum inhabit a broad range of environments. Most species are free-living, feeding on microorganisms, but many are parasitic. Parasitic worms (hel ...
", or ''cun baichong'' 寸白蟲 "inch-long white worm;
nematode The nematodes ( or ; ; ), roundworms or eelworms constitute the phylum Nematoda. Species in the phylum inhabit a broad range of environments. Most species are free-living, feeding on microorganisms, but many are parasitic. Parasitic worms (h ...
", and says the supposed six TB worms are "six kinds" of parasites, but the next chapter (24/20a-21b) says they are "six stages/generations" of reproduction. Daoist priests allegedly cured tuberculosis through drugs, acupuncture, and burning ''
fulu () are Asemic writing, asemic Daoist, Taoist magic symbols and incantations, translatable into English as 'talismanic script', which are written or painted on talismans by Taoist practitioners. These practitioners are called , an informal gr ...
'' "supernatural talismans/charms". Burning magic talismans would cause the TB patient to cough, which was considered an effective treatment. In addition, Daoist healers would burn talismans in order to fumigate the clothes and belongings of the deceased, and would warn the tuberculosis patient's family to throw away everything into a ''changliu shui'' 長流水 "everflowing stream". According to Liu Ts'un-yan, "This proves that the priests of the time actually wanted to destroy all the belongings of the deceased, using charms as a camouflage."


Classical antiquity

Hippocrates Hippocrates of Kos (; ; ), also known as Hippocrates II, was a Greek physician and philosopher of the Classical Greece, classical period who is considered one of the most outstanding figures in the history of medicine. He is traditionally referr ...
, in Book 1 of his ''Of the Epidemics,'' describes the characteristics of the disease: fever, colourless urine, cough resulting in a thick sputa, and loss of thirst and appetite. He notes that most of those affected became delirious before they died from the disease. Hippocrates and many other at the time believed phthisis to be hereditary in nature. Aristotle disagreed, believing the disease was contagious.
Pliny the Younger Gaius Plinius Caecilius Secundus (born Gaius Caecilius or Gaius Caecilius Cilo; 61 – ), better known in English as Pliny the Younger ( ), was a lawyer, author, and magistrate of Ancient Rome. Pliny's uncle, Pliny the Elder, helped raise and e ...
wrote a letter to Priscus in which he details the symptoms of phthisis as he saw them in Fannia:
Galen Aelius Galenus or Claudius Galenus (; September 129 – AD), often Anglicization, anglicized as Galen () or Galen of Pergamon, was a Ancient Rome, Roman and Greeks, Greek physician, surgeon, and Philosophy, philosopher. Considered to be one o ...
proposed a series of therapeutic treatments for the disease, including:
opium Opium (also known as poppy tears, or Lachryma papaveris) is the dried latex obtained from the seed Capsule (fruit), capsules of the opium poppy ''Papaver somniferum''. Approximately 12 percent of opium is made up of the analgesic alkaloid mor ...
as a sleeping agent and painkiller; blood letting; a diet of barley water, fish, and fruit. He also described the phyma (tumor) of the lungs, which is thought to correspond to the tubercles that form on the lung as a result of the disease.
Vitruvius Vitruvius ( ; ; –70 BC – after ) was a Roman architect and engineer during the 1st century BC, known for his multi-volume work titled . As the only treatise on architecture to survive from antiquity, it has been regarded since the Renaissan ...
noted that "cold in the windpipe, cough, plurisy, phthisis, ndspitting blood", were common diseases in regions where the wind blew from north to northwest, and advised that walls be so built as to shelter individuals from the winds. Aretaeus was the first person to rigorously describe the symptoms of the disease in his text ''De causis et signis diuturnorum morborum'': In his other book ''De curatione diuturnorum morborum'', he recommends that affected individuals travel to high altitudes, travel by sea, eat a good diet and drink plenty of milk.Stivelman 1931:128


Pre-Columbian America

In South America, reports of a study in August 2014 revealed that TB had likely been spread via seals that contracted it on beaches of Africa, from humans via domesticated animals, and carried it across the Atlantic. A team at the
University of Tübingen The University of Tübingen, officially the Eberhard Karl University of Tübingen (; ), is a public research university located in the city of Tübingen, Baden-Württemberg, Germany. The University of Tübingen is one of eleven German Excellenc ...
analyzed tuberculosis DNA in 1,000-year-old skeletons of the
Chiribaya culture The Chiribaya culture flourished near the coast of southern Peru and adjacent Chile from 700 CE until Spanish settlement in the late 16th century. The classic phase of the Chiribaya culture was from 1000 CE until 1360 CE. The Chiribaya culture co ...
in southern Peru; so much genetic material was recovered that they could reconstruct the genome. They learned that this TB strain was related most closely to a form found only in seals.Carl Zimmer, "Tuberculosis Is Newer Than Thought, Study Says"
''New York Times'', 21 August 2014
In South America, it was likely contracted first by hunters who handled contaminated meat. This TB is a different strain from that prevalent today in the Americas, which is more closely related to a later Eurasian strain. Prior to this study, the first evidence of the disease in South America was found in remains of the
Arawak The Arawak are a group of Indigenous peoples of northern South America and of the Caribbean. The term "Arawak" has been applied at various times to different Indigenous groups, from the Lokono of South America to the Taíno (Island Arawaks), w ...
culture around 1050 BC.Prat 2003:153 The most significant finding belongs to the mummy of an 8 to 10-year-old Nascan child from Hacienda Agua Sala, dated to 700 AD. Scientists were able to isolate evidence of the bacillus.


Europe: Middle Ages and Renaissance

During the Middle Ages, no significant advances were made regarding tuberculosis.
Avicenna Ibn Sina ( – 22 June 1037), commonly known in the West as Avicenna ( ), was a preeminent philosopher and physician of the Muslim world, flourishing during the Islamic Golden Age, serving in the courts of various Iranian peoples, Iranian ...
and
Rhazes Abū Bakr al-Rāzī, also known as Rhazes (full name: ), , was a Persian physician, philosopher and alchemist who lived during the Islamic Golden Age. He is widely regarded as one of the most important figures in the history of medicine, and a ...
continued to consider the disease both contagious and difficult to treat.
Arnaldus de Villa Nova Arnaldus de Villa Nova (also called Arnau de Vilanova, Arnaldus Villanovanus, Arnaud de Ville-Neuve or Arnaldo de Villanueva, c. 1240–1311) was a physician and a religious reformer. He is credited with translating a number of medical texts ...
described etiopathogenic theory directly related to that of Hippocrates, in which a cold humor dripped from the head into the lungs. In
Medieval In the history of Europe, the Middle Ages or medieval period lasted approximately from the 5th to the late 15th centuries, similarly to the post-classical period of World history (field), global history. It began with the fall of the West ...
Hungary Hungary is a landlocked country in Central Europe. Spanning much of the Pannonian Basin, Carpathian Basin, it is bordered by Slovakia to the north, Ukraine to the northeast, Romania to the east and southeast, Serbia to the south, Croatia and ...
, the Inquisition recorded the trials of pagans. A document from the 12th century recorded an explanation of the cause of illness. The pagans said that tuberculosis was produced when a dog-shaped demon occupied the person's body and started to eat his lungs. When the possessed person coughed, then the demon was barking, and getting close to his objective, which was to kill the victim.


Royal touch

Monarchs were seen as religious figures with magical or curative powers. It was believed that
royal touch The royal touch (also known as the king's touch) was a form of laying on of hands, whereby List of French monarchs, French and English monarchs touched their subjects, regardless of social classes, with the intent to cure them of various diseas ...
, the touch of the
sovereign ''Sovereign'' is a title that can be applied to the highest leader in various categories. The word is borrowed from Old French , which is ultimately derived from the Latin">-4; we might wonder whether there's a point at which it's appropriate to ...
of England or France, could cure diseases due to the divine right of sovereigns.Maulitz and Maulitz 1973:87 King
Henry IV of France Henry IV (; 13 December 1553 – 14 May 1610), also known by the epithets Good King Henry (''le Bon Roi Henri'') or Henry the Great (''Henri le Grand''), was King of Navarre (as Henry III) from 1572 and King of France from 1589 to 16 ...
usually performed the rite once a week, after taking communion.Dang 2001:231 So common was this practice of royal healing in France, that scrofula became known as the "''mal du roi''" or the "King's Evil". Initially, the touching ceremony was an informal process. Sickly individuals could petition the court for a royal touch and the touch would be performed at the King's earliest convenience. At times, the
King of France France was ruled by monarchs from the establishment of the kingdom of West Francia in 843 until the end of the Second French Empire in 1870, with several interruptions. Classical French historiography usually regards Clovis I, king of the Fra ...
would touch affected subjects during his royal walkabout. The rapid spread of tuberculosis across France and England, however, necessitated a more formal and efficient touching process. By the time of
Louis XIV of France LouisXIV (Louis-Dieudonné; 5 September 16381 September 1715), also known as Louis the Great () or the Sun King (), was King of France from 1643 until his death in 1715. His verified reign of 72 years and 110 days is the List of longest-reign ...
, placards indicating the days and times the King would be available for royal touches were posted regularly; sums of money were doled out as charitable support.Aufderheide 1998:129 In England, the process was extremely formal and efficient. As late as 1633, the
Book of Common Prayer The ''Book of Common Prayer'' (BCP) is the title given to a number of related prayer books used in the Anglican Communion and by other Christianity, Christian churches historically related to Anglicanism. The Book of Common Prayer (1549), fi ...
of the
Anglican Church Anglicanism, also known as Episcopalianism in some countries, is a Western Christianity, Western Christian tradition which developed from the practices, liturgy, and identity of the Church of England following the English Reformation, in the ...
contained a Royal Touch ceremony. The
monarch A monarch () is a head of stateWebster's II New College Dictionary. "Monarch". Houghton Mifflin. Boston. 2001. p. 707. Life tenure, for life or until abdication, and therefore the head of state of a monarchy. A monarch may exercise the highest ...
(king or queen), sitting upon a canopied throne, touched the affected individual, and presented that individual with a
coin A coin is a small object, usually round and flat, used primarily as a medium of exchange or legal tender. They are standardized in weight, and produced in large quantities at a mint in order to facilitate trade. They are most often issued by ...
– usually an
Angel An angel is a spiritual (without a physical body), heavenly, or supernatural being, usually humanoid with bird-like wings, often depicted as a messenger or intermediary between God (the transcendent) and humanity (the profane) in variou ...
, a gold coin the value of which varied from about 6
shillings The shilling is a historical coin, and the name of a unit of modern currencies formerly used in the United Kingdom, Australia, New Zealand, other British Commonwealth countries and Ireland, where they were generally equivalent to 12 pence ...
to about 10 shillings – by pressing it against the affected's neck. Although the ceremony was of no medical value, members of the royal courts often propagandized that those receiving the royal touch were miraculously healed. André du Laurens, the senior physician of Henry IV, publicized findings that at least half of those that received the royal touch were cured within a few days. The royal touch remained popular into the 18th century. Parish registers from
Oxfordshire Oxfordshire ( ; abbreviated ''Oxon'') is a ceremonial county in South East England. The county is bordered by Northamptonshire and Warwickshire to the north, Buckinghamshire to the east, Berkshire to the south, and Wiltshire and Glouceste ...
, England include not only records of baptisms, marriages, and deaths, but also records of those eligible for the royal touch.


Contagion

Girolamo Fracastoro Girolamo Fracastoro (; c. 1476/86 August 1553) was an Italian physician, poet, and scholar in mathematics, geography and astronomy. Fracastoro subscribed to the philosophy of atomism, and rejected appeals to hidden causes in scientific investiga ...
became the first person to propose, in his work ''De contagione'' in 1546, that phthisis was transmitted by an invisible ''virus''. Among his assertions were that the ''virus'' could survive between ''two or three years'' on the clothes of those with the disease and that it was usually transmitted through direct contact or the discharged fluids of the infected, what he called ''fomes''. He noted that phthisis could be contracted without either direct contact or fomes, but was unsure of the process by which the disease propagated across distances.


Paracelsus's tartaric process

Paracelsus Paracelsus (; ; 1493 – 24 September 1541), born Theophrastus von Hohenheim (full name Philippus Aureolus Theophrastus Bombastus von Hohenheim), was a Swiss physician, alchemist, lay theologian, and philosopher of the German Renaissance. H ...
advanced the belief that tuberculosis was caused by a failure of an internal organ to accomplish its alchemical duties. When this occurred in the lungs, stony precipitates would develop causing tuberculosis in what he called the ''tartaric'' process.


Seventeenth and eighteenth centuries

Franciscus Sylvius Franciscus Sylvius (, ; born Franz de le Boë; 15 March 1614 – 19 November 1672) was a Dutch physician and scientist (chemist, physiologist and anatomist) who was an early champion of Descartes', Van Helmont's and William Harvey's work ...
began differentiating between the various forms of tuberculosis (pulmonary, ganglion). He was the first person to recognize that the skin ulcers caused by scrofula resembled tubercles seen in phthisis,Ancell 1852:549 noting that "phthisis is the scrofula of the lung" in his book ''Opera Medica'', published posthumously in 1679. Around the same time,
Thomas Willis Thomas Willis Fellow of the Royal Society, FRS (27 January 1621 – 11 November 1675) was an English physician who played an important part in the history of anatomy, neurology, and psychiatry, and was a founding member of the Royal Society. L ...
concluded that all diseases of the chest must ultimately lead to consumption. Willis did not know the exact cause of the disease but he blamed it on sugar or an acidity of the blood. Richard Morton published ''Phthisiologia, seu exercitationes de Phthisi tribus libris comprehensae'' in 1689, in which he emphasized the tubercle as the true cause of the disease. So common was the disease at the time that Morton is quoted as saying "I cannot sufficiently admire that anyone, at least after he comes to the flower of his youth, can dye without a touch of consumption." In 1720, Benjamin Marten proposed in ''A New Theory of Consumptions more Especially of Phthisis or Consumption of the Lungs'' that the cause of tuberculosis was some type of ''animalcula''—microscopic living beings that are able to survive in a new body (similar to the ones described by
Anton van Leeuwenhoek Antonie Philips van Leeuwenhoek ( ; ; 24 October 1632 – 26 August 1723) was a Dutch microbiologist and microscopist in the Golden Age of Dutch art, science and technology. A largely self-taught man in science, he is commonly known as " ...
in 1695). The theory was roundly rejected and it took another 162 years before Robert Koch demonstrated it to be true. In 1768,
Robert Whytt Robert Whytt (1714–1766) was a Scottish physician. His work, on unconscious reflexes, tubercular meningitis, urinary bladder stones, and hysteria, is remembered now most for his book on diseases of the nervous system. He served as President of ...
gave the first clinical description of tuberculosis meningitis and, in 1779,
Percivall Pott Percivall Pott (6 January 1714, in London – 22 December 1788) was an English surgeon, one of the founders of orthopaedics, and the first scientist to demonstrate that cancer may be caused by an environmental carcinogen, namely chimney sweeps ...
, an English surgeon, described the vertebral lesions that carry his name. In 1761,
Leopold Auenbrugger Josef Leopold Auenbrugger or Avenbrugger (19 November 1722 – 17 May 1809), also known as Leopold von Auenbrugger, was an Austrian physician who invented percussion as a diagnostic technique. On the strength of this discovery, he is considered ...
, an Austrian physician, developed the percussion method of diagnosing tuberculosis,Daniel 2000:45 a method rediscovered some years later in 1797 by Jean-Nicolas Corvisart of France. After finding it useful, Corvisart made it readily available to the academic community by translating it into French. William Stark proposed that ordinary lung tubercles could eventually evolve into ulcers and cavities, believing that the different forms of tuberculosis were simply different manifestations of the same disease. Unfortunately, Stark died at the age of 30 (while studying
scurvy Scurvy is a deficiency disease (state of malnutrition) resulting from a lack of vitamin C (ascorbic acid). Early symptoms of deficiency include weakness, fatigue, and sore arms and legs. Without treatment, anemia, decreased red blood cells, gum d ...
) and his observations were discounted. In his ''Systematik de speziellen Pathologie und Therapie'', J. L. Schönlein, Professor of Medicine in Zurich, proposed that the word "tuberculosis" be used to describe the condition of tubercles. The incidence of tuberculosis grew progressively during the Middle Ages and Renaissance, displacing
leprosy Leprosy, also known as Hansen's disease (HD), is a Chronic condition, long-term infection by the bacteria ''Mycobacterium leprae'' or ''Mycobacterium lepromatosis''. Infection can lead to damage of the Peripheral nervous system, nerves, respir ...
, peaking between the 18th and 19th century as field workers moved to the cities looking for work. When he released his study in 1808, William Woolcombe was astonished at the prevalence of tuberculosis in 18th-century England. Of the 1,571 deaths in the English city of
Bristol Bristol () is a City status in the United Kingdom, cathedral city, unitary authority area and ceremonial county in South West England, the most populous city in the region. Built around the River Avon, Bristol, River Avon, it is bordered by t ...
between 1790 and 1796, 683 were due to tuberculosis. Remote towns, initially isolated from the disease, slowly succumbed. The consumption deaths in the village of Holycross in
Shropshire Shropshire (; abbreviated SalopAlso used officially as the name of the county from 1974–1980. The demonym for inhabitants of the county "Salopian" derives from this name.) is a Ceremonial counties of England, ceremonial county in the West M ...
between 1750 and 1759 were one in six (1:6); ten years later, 1:3. In the metropolis of London, 1:7 died from consumption at the dawn of the 18th century, by 1750 that proportion grew to 1:5.25 and surged to 1:4.2 by around the start of the 19th century. The
Industrial Revolution The Industrial Revolution, sometimes divided into the First Industrial Revolution and Second Industrial Revolution, was a transitional period of the global economy toward more widespread, efficient and stable manufacturing processes, succee ...
coupled with poverty and squalor created the optimal environment for the propagation of the disease.


Nineteenth century


Epidemic tuberculosis

In the 18th and 19th century, tuberculosis (TB) had become
epidemic An epidemic (from Greek ἐπί ''epi'' "upon or above" and δῆμος ''demos'' "people") is the rapid spread of disease to a large number of hosts in a given population within a short period of time. For example, in meningococcal infection ...
in Europe, showing a seasonal pattern. In the 18th century, TB had a mortality rate as high as 900 deaths (800–1000) per 100,000 population per year in
Western Europe Western Europe is the western region of Europe. The region's extent varies depending on context. The concept of "the West" appeared in Europe in juxtaposition to "the East" and originally applied to the Western half of the ancient Mediterranean ...
, including in places like London,
Stockholm Stockholm (; ) is the Capital city, capital and List of urban areas in Sweden by population, most populous city of Sweden, as well as the List of urban areas in the Nordic countries, largest urban area in the Nordic countries. Approximately ...
and
Hamburg Hamburg (, ; ), officially the Free and Hanseatic City of Hamburg,. is the List of cities in Germany by population, second-largest city in Germany after Berlin and List of cities in the European Union by population within city limits, 7th-lar ...
. A similar death rate occurred in North America. In the United Kingdom, epidemic TB may have peaked around 1750, as suggested by mortality data. In the 19th century, TB killed about a quarter of the adult population of Europe. In western continental Europe, epidemic TB may have peaked in the first half of the 19th century. In addition, between 1851 and 1910, around four million died from TB in England and Wales – more than one third of those aged 15 to 34 and half of those aged 20 to 24 died from TB. By the late 19th century, 70–90% of the urban populations of Europe and North America were infected with the ''
Mycobacterium tuberculosis ''Mycobacterium tuberculosis'' (M. tb), also known as Koch's bacillus, is a species of pathogenic bacteria in the family Mycobacteriaceae and the causative agent of tuberculosis. First discovered in 1882 by Robert Koch, ''M. tuberculosis'' ha ...
'', and about 80% of those individuals who developed active TB died of it. However, mortality rates began declining in the late 19th century throughout Europe and the United States. At the time, tuberculosis was called ''the robber of youth,'' because the disease had higher death rate among young people. Other names included ''the'' ''Great White Plague'' and ''the White Death'', where the "white" was due to the extreme anaemic pallor of those infected. In addition, TB has been called by many as the "Captain of All These Men of Death".


A romantic disease

It was during this century that tuberculosis was dubbed the White Plague, ''mal de vivre'', and ''mal du siècle''. It was seen as a "romantic disease". Individuals with tuberculosis were thought to have heightened sensitivity. The slow progress of the disease allowed for a "good death" as those affected could arrange their affairs. The disease began to represent spiritual purity and temporal wealth, leading many young, upper-class women to purposefully pale their skin to achieve the consumptive appearance. British poet
Lord Byron George Gordon Byron, 6th Baron Byron (22 January 1788 – 19 April 1824) was an English poet. He is one of the major figures of the Romantic movement, and is regarded as being among the greatest poets of the United Kingdom. Among his best-kno ...
wrote, "I should like to die from consumption", helping to popularize the disease as the disease of artists.
George Sand Amantine Lucile Aurore Dupin de Francueil (; 1 July 1804 – 8 June 1876), best known by her pen name George Sand (), was a French novelist, memoirist and journalist. Being more renowned than either Victor Hugo or Honoré de Balz ...
doted on her phthisic lover,
Frédéric Chopin Frédéric François Chopin (born Fryderyk Franciszek Chopin; 1 March 181017 October 1849) was a Polish composer and virtuoso pianist of the Romantic period who wrote primarily for Piano solo, solo piano. He has maintained worldwide renown ...
, calling him her "poor melancholy angel".Daniel 2006:1864 In France, at least five novels were published expressing the ideals of tuberculosis: Dumas's ''
La Dame aux camélias ''The Lady of the Camellias'' (), sometimes called ''Camille'' in English, is a novel by Alexandre Dumas ''fils''. First published in 1848 and subsequently adapted by Dumas for the stage, the play premiered at the Théâtre du Vaudeville in P ...
'', Murger's '' Scènes de la vie de Bohème'', Hugo's ''
Les Misérables ''Les Misérables'' (, ) is a 19th-century French literature, French Epic (genre), epic historical fiction, historical novel by Victor Hugo, first published on 31 March 1862, that is considered one of the greatest novels of the 19th century. '' ...
'', the
Goncourt brothers The Goncourt brothers (, , ) were Edmond de Goncourt (1822–1896) and Jules de Goncourt (1830–1870), both French naturalism writers who, as collaborative sibling authors, were inseparable in life. Background Edmond and Jules were born to ...
' ''Madame Gervaisais'' and ''Germinie Lacerteux'', and Rostand's '' L'Aiglon''. The portrayals by Dumas and Murger in turn inspired operatic depictions of consumption in Verdi's '' La traviata'' and Puccini's ''
La bohème ''La bohème'' ( , ) is an opera in four acts,Puccini called the divisions '':wikt:quadro, quadri'', ''wikt:tableau, tableaux'' or "images", rather than ''atti'' (acts). composed by Giacomo Puccini between 1893 and 1895 to an Italian libretto b ...
''. Even after medical knowledge of the disease had accumulated, the redemptive-spiritual perspective of the disease has remained popular (as seen in the 2001 film ''Moulin Rouge'' based in part on ''La traviata''; the 2013 film '' The Wind Rises'', based in part on a 1937 novel about tuberculosis; and the musical adaptations of ''Les Misérables''). In large cities the poor had high rates of tuberculosis. Public-health physicians and politicians typically blamed both the poor themselves and their ramshackle tenement houses (conventillos) for the spread of the dreaded disease. People ignored public-health campaigns to limit the spread of contagious diseases, such as the prohibition of spitting on the streets, the strict guidelines to care for infants and young children, and quarantines that separated families from ill loved ones.


Scientific advances

Though removed from the cultural movement, the scientific understanding advanced considerably. By the end of the 19th century, several major breakthroughs gave hope that a cause and cure might be found. One of the most important physicians dedicated to the study of phthisiology was
René Laennec René-Théophile-Hyacinthe Laennec (; 17 February 1781 – 13 August 1826) was a French physician and musician. His skill at carving his own wooden flutes led him to invent the stethoscope in 1816, while working at the Hôpital Necker. ...
, who died from the disease at the age of 45, after contracting tuberculosis while studying contagious patients and infected bodies. Laennec invented the
stethoscope The stethoscope is a medicine, medical device for auscultation, or listening to internal sounds of an animal or human body. It typically has a small disc-shaped resonator that is placed against the skin, with either one or two tubes connected t ...
which he used to corroborate his auscultatory findings and prove the correspondence between the pulmonary lesions found on the lungs of autopsied tuberculosis patients and the respiratory symptoms seen in living patients. His most important work was ''Traité de l'Auscultation Médiate'' which detailed his discoveries on the utility of pulmonary auscultation in diagnosing tuberculosis. This book was promptly translated into English by John Forbes in 1821; it represents the beginning of the modern scientific understanding of tuberculosis. Laennec was named professional chair of Hôpital Necker in September 1816 and today he is considered the greatest French clinician. Laennec's work put him in contact with the vanguard of the French medical establishment, including
Pierre Charles Alexandre Louis Pierre-Charles-Alexandre Louis (14 April 178722 August 1872) was a French physician, clinician and pathologist known for his studies on tuberculosis, typhoid fever, and pneumonia, but Louis's greatest contribution to medicine was the development ...
. Louis would go on to use statistical methods to evaluate the different aspects of the disease's progression, the efficacy of various therapies and individuals' susceptibility, publishing an article in the ''Annales d'hygiène publique'' entitled "Note on the Relative Frequency of Phthisis in the Two Sexes". Another good friend and co-worker of Laennec, Gaspard Laurent Bayle, published an article in 1810 entitled ''Recherches sur la Pthisie Pulmonaire'', in which he divided pthisis into six types: tubercular phthisis, glandular phthisis, ulcerous phthisis, phthisis with melanosis, calculous phthisis, and cancerous phthisis. He based his findings on more than 900 autopsies. In 1869, Jean Antoine Villemin demonstrated that the disease was indeed contagious, conducting an experiment in which tuberculous matter from human cadavers was injected into laboratory rabbits, which then became infected. On 24 March 1882, Robert Koch revealed the disease was caused by an infectious agent. In 1895,
Wilhelm Röntgen Wilhelm Conrad Röntgen (; 27 March 1845 – 10 February 1923), sometimes Transliteration, transliterated as Roentgen ( ), was a German physicist who produced and detected electromagnetic radiation in a wavelength range known as X-rays. As ...
discovered the X-ray, which allowed physicians to diagnose and track the progression of the disease, and although an effective medical treatment would not come for another fifty years, the incidence and mortality of tuberculosis began to decline.


Robert Koch

Villemin's experiments had confirmed the contagious nature of the disease and had forced the medical community to accept that tuberculosis was indeed an infectious disease, transmitted by some etiological agent of unknown origin. In 1882, Prussian physician
Robert Koch Heinrich Hermann Robert Koch ( ; ; 11 December 1843 – 27 May 1910) was a German physician and microbiologist. As the discoverer of the specific causative agents of deadly infectious diseases including tuberculosis, cholera and anthrax, he i ...
utilized a new staining method and applied it to the sputum of tuberculosis patients, revealing for the first time the causal agent of the disease: ''Mycobacterium tuberculosis'', or Koch's bacillus. When he began his investigation, Koch knew of the work of Villemin and others who had continued his experiments like Julius Conheim and Carl Salmosen. He also had access to the "pthisis ward" at the Berlin Charité Hospital. Before he confronted the problem of tuberculosis, he worked with the disease caused by anthrax and had discovered the causal agent to be ''Bacillus anthracis''. During this investigation he became friends with Ferdinand Cohn, the director of the Institute of Vegetable Physiology. Together they worked to develop methods of culturing tissue samples. 18 August 1881, while staining tuberculous material with
methylene blue Methylthioninium chloride, commonly called methylene blue, is a salt used as a dye and as a medication. As a medication, it is mainly used to treat methemoglobinemia. It has previously been used for treating cyanide poisoning and urinary trac ...
, he noticed oblong structures, though he was not able to ascertain whether it was just a result of the coloring. To improve the contrast, he decided to add Bismarck Brown, after which the oblong structures were rendered bright and transparent. He improved the technique by varying the concentration of alkali in the staining solution until the ideal viewing conditions for the bacilli was achieved. After numerous attempts he was able to incubate the bacteria in coagulated blood serum at 37 degrees Celsius. He then inoculated laboratory rabbits with the bacteria and observed that they died while exhibiting symptoms of tuberculosis, proving that the bacillus, which he named ''tuberculosis bacillus'', was in fact the cause of tuberculosis.Koch 1882 He made his result public at the Physiological Society of Berlin on 24 March 1882, in a famous lecture entitled ''Über Tuberculose'', which was published three weeks later. Since 1882, 24 March has been known as
World Tuberculosis Day World Tuberculosis Day, observed on 24 March each year, is designed to build public awareness about the global epidemic of tuberculosis (TB) and efforts to eliminate the disease. In 2018, 10 million people fell ill with TB, and 1.5 million di ...
. On 20 April 1882, Koch presented an article entitled ''Die Ätiologie der Tuberculose'' in which he demonstrated that ''Mycobacterium'' was the single cause of tuberculosis in all of its forms. In 1890 Koch developed
tuberculin Tuberculin, also known as purified protein derivative, is a combination of proteins that are used in the diagnosis of tuberculosis. This use is referred to as the tuberculin skin test and is recommended only for those at high risk. Reliable adm ...
, a purified protein derivative of the bacteria. Data on experimental inquiry published in Deutsche Landwirthschafts-Zeitung provided immediate practical industry benefits in the form of the
Tuberculin test The Mantoux test or Mendel–Mantoux test (also known as the Mantoux screening test, tuberculin sensitivity test, Pirquet test, or PPD test for purified protein derivative) is a tool for screening for tuberculosis (TB) and for tuberculosis dia ...
as an aide to
diagnosis Diagnosis (: diagnoses) is the identification of the nature and cause of a certain phenomenon. Diagnosis is used in a lot of different academic discipline, disciplines, with variations in the use of logic, analytics, and experience, to determine " ...
in both sick and healthy cattle. Tuberculin proved to be an ineffective means of immunization but in 1908,
Charles Mantoux Charles Mantoux (; May 14, 1877, Paris – May 3, 1947, Le Cannet) was a French physician and the developer of the eponymous serological test for tuberculosis. Biography Mantoux graduated from the University of Paris, where he studied under B ...
found it was an effective intradermic test for diagnosing tuberculosis.


Sanatorium movement

The advancement of scientific understanding of tuberculosis, and its contagious nature created the need for institutions to house affected individuals. The first proposal for a tuberculosis facility was made in paper by
George Bodington George Bodington (1799–1882) was a British general practitioner and pulmonary specialist. Career Born in Buckinghamshire and educated at Magdalen College, Oxford, he served a surgeon, surgical apprenticeship then studied at St Bartholomew's H ...
entitled ''An essay on the treatment and cure of pulmonary consumption, on principles natural, rational and successful'' in 1840. In this paper, he proposed a dietary, rest, and medical care program for a hospital he planned to found in Maney. Attacks from numerous medical experts, especially articles in ''The Lancet'', disheartened Bodington and he turned to plans for housing the insane.
Hermann Brehmer Hermann Brehmer (14 August 1826 – 28 December 1889) was a German physician who established the first German sanatorium for the systematic open-air treatment of tuberculosis. Biography Brehmer was born in Kurtsch (Kurczów) near Strehlen (Strz ...
, a German physician, was convinced that tuberculosis arose from the difficulty of the heart to correctly irrigate the lungs. He therefore proposed that regions well above sea level, where the atmospheric pressure was less, would help the heart function more effectively. With the encouragement of explorer
Alexander von Humboldt Friedrich Wilhelm Heinrich Alexander von Humboldt (14 September 1769 – 6 May 1859) was a German polymath, geographer, natural history, naturalist, List of explorers, explorer, and proponent of Romanticism, Romantic philosophy and Romanticism ...
and his teacher J. L. Schönlein, the first anti-tuberculosis sanatorium was established in 1854, 650 meters above sea level, at Görbersdorf. Three years later he published his findings in a book ''Die chronische Lungenschwindsucht und Tuberkulose der Lunge: Ihre Ursache und ihre Heilung''. Brehmer and one of his patients, Peter Dettweiler, became proponents for the sanatorium movement, and by 1877, sanatoriums began to spread beyond Germany and throughout Europe. Dr.
Edward Livingston Trudeau Edward Livingston Trudeau (October 5, 1848 – November 15, 1915) was an American physician who established the Adirondack Cottage Sanitarium at Saranac Lake, New York, Saranac Lake for the treatment of tuberculosis. Dr. Trudeau also establi ...
subsequently founded the Adirondack Cottage Sanitorium in
Saranac Lake, New York Saranac Lake is a village in the state of New York, United States. As of the 2020 census, the population was 4,887, making it the largest community by population in the Adirondack Park.U.S. Census Bureau, 2020 Report, Saranac Lake village, New ...
in 1884. One of Trudeau's early patients was author
Robert Louis Stevenson Robert Louis Stevenson (born Robert Lewis Balfour Stevenson; 13 November 1850 – 3 December 1894) was a Scottish novelist, essayist, poet and travel writer. He is best known for works such as ''Treasure Island'', ''Strange Case of Dr Jekyll ...
; his fame helped establish Saranac Lake as a center for the treatment of tuberculosis. In 1894, after a fire destroyed Trudeau's small home laboratory, he organized the Saranac Laboratory for the Study of Tuberculosis; renamed the
Trudeau Institute The Trudeau Institute is an independent, not-for-profit, biomedical research center located on a campus in Saranac Lake, New York. Its scientific mission is to make breakthrough discoveries that lead to improved human health. Its current presi ...
, the laboratory continues to study infectious diseases. Peter Dettweiler went on to found his own sanatorium at Falkenstein in 1877 and in 1886 published findings claiming that 132 of his 1022 patients had been completely cured after staying at his institution. Eventually, sanatoriums began to appear near large cities and at low altitudes, like the Sharon Sanatorium in 1890 near Boston.Shryock 1977:47 Sanatoriums were not the only treatment facilities. Specialized tuberculosis clinics began to develop in major metropolitan areas. Sir Robert Philip established the Royal Victoria Dispensary for Consumption in
Edinburgh Edinburgh is the capital city of Scotland and one of its 32 Council areas of Scotland, council areas. The city is located in southeast Scotland and is bounded to the north by the Firth of Forth and to the south by the Pentland Hills. Edinburgh ...
in 1887.
Dispensaries A dispensary is an office in a school, hospital, industrial plant, or other organization that dispenses medications, medical supplies, and in some cases even medical and dental treatment. In a traditional dispensary set-up, a pharmacist dispense ...
acted as special sanatoriums for early tuberculosis cases and were opened to lower income individuals. The use of dispensaries to treat middle and lower-class individuals in major metropolitan areas and the coordination between various levels of health services programs like hospitals, sanatoriums, and tuberculosis colonies became known as the "Edinburgh Anti-tuberculosis Scheme".


Twentieth century


Containment

At the beginning of the 20th century, tuberculosis was one of the UK's most urgent health problems. A royal commission was set up in 1901, The Royal Commission Appointed to Inquire into the Relations of Human and Animal Tuberculosis. Its remit was to find out whether tuberculosis in animals and humans was the same disease, and whether animals and humans could infect each other. By 1919, the Commission had evolved into the UK's Medical Research Council. In 1902, the International Conference on Tuberculosis convened in Berlin. Among various other acts, the conference proposed the
Cross of Lorraine The Cross of Lorraine (), known as the Cross of Anjou in the 16th century, is a heraldry, heraldic two-barred cross, consisting of a vertical line crossed by two shorter horizontal bars. In most renditions, the horizontal bars are "graded" with ...
be the international symbol of the fight against tuberculosis. National campaigns spread across Europe and the United States to tamp down on the continued prevalence of tuberculosis. After the establishment in the 1880s that the disease was contagious, TB was made a notifiable disease in Britain; there were campaigns to stop spitting in public places, and the infected poor were pressured to enter sanatoria that resembled prisons; the sanatoria for the middle and upper classes offered excellent care and constant medical attention.McCarthy 2001:413-7 Whatever the purported benefits of the fresh air and labor in the sanatoria, even under the best conditions, 50% of those who entered were dead within five years (1916). The promotion of Christmas Seals began in Denmark during 1904 as a way to raise money for tuberculosis programs. It expanded to the United States and Canada in 1907–1908 to help the National Tuberculosis Association (later called the American Lung Association). In the United States, concern about the spread of tuberculosis played a role in the movement to prohibit public spitting except into spittoons. Public health measures were inaugurated to track and control the prevalence of tuberculosis in livestock that could be transmitted to humans.


Vaccines

The first genuine success in immunizing against tuberculosis was developed from attenuated bovine-strain tuberculosis by Albert Calmette and Camille Guérin in 1906. It was called "BCG" (''Bacillus Calmette-Guérin, Bacille Calmette-Guérin''). The BCG vaccine was first used on humans in 1921 in France, but it was not until after World War II that BCG received widespread acceptance in Great Britain and Germany. In the early days of the British National Health Service X-ray examination for TB increased dramatically but rates of vaccination were initially very low. In 1953 it was agreed that secondary school pupils should be vaccinated, but by the end of 1954 only 250,000 people had been vaccinated. By 1956 this had risen to 600,000, about half being school children. In Italy, Salvioli's diffusing vaccine (; VDS) was used from 1948 until 1976. It was developed by Professor Gaetano Salvioli (1894–1982) of the University of Bologna.


Treatments

As the century progressed, some surgical interventions, including the pneumothorax or plombage technique—collapsing an infected lung to "rest" it and allow the lesions to heal—were used to treat tuberculosis. Pneumothorax was not a new technique by any means. In 1696, Giorgio Baglivi reported a general improvement in tuberculosis patients after they received sword wounds to the chest. F.H. Ramadge induced the first successful therapeutic pneumothorax in 1834, and reported subsequently the patient was cured. It was in the 20th century, however, that scientists sought to rigorously investigate the effectiveness of such procedures. Carlo Forlanini experimented with his artificial pneumothorax technique from 1882 to 1888 and this started to be followed only years later. In 1939, the ''British Journal of Tuberculosis'' published a study by Oli Hjaltested and Kjeld Törning on 191 patients undergoing the procedure between 1925 and 1931; in 1951, Roger Mitchell published several articles on the therapeutic outcomes of 557 patients treated between 1930 and 1939 at Adirondack Cottage Sanitarium, Trudeau Sanatorium in Saranac Lake, New York, Saranac Lake. The search for a medicinal cure, however, continued in earnest. During the Nazi occupation of Poland, SS-Obergruppenführer Wilhelm Koppe organized the execution of more than 30,000 Polish patients with tuberculosis – little knowing or caring that a cure was nearly at hand. In 1944 Albert Schatz (scientist), Albert Schatz, Elizabeth Bugie, and Selman Waksman isolated streptomycin produced by a bacterial strain ''Streptomyces griseus.'' Streptomycin was the first effective antibiotic against ''M. tuberculosis''.Daniel 2006:1868 This discovery is generally considered the beginning of the modern era of tuberculosis. Para-aminosalicylic acid, discovered in 1946, was used in combination with Streptomycin to reduce the emergence of drug resistant variants, which greatly improved patient outcomes. The true revolution began some years later, in 1952, with the development of isoniazid, the first oral mycobactericidal drug. The advent of rifampin in the 1970s hastened recovery times, and significantly reduced the number of tuberculosis cases until the 1980s. The British epidemiologist Thomas McKeown (physician), Thomas McKeown had shown that "treatment by streptomycin reduced the number of deaths since it was introduced (1948–71) by 51 per cent...". However, he also showed that the mortality from TB in England and Wales had already declined by 90 to 95% before streptomycin and BCG-vaccination were widely available, and that the contribution of antibiotics to the decline of mortality from TB was actually very small: ''...for the total period since cause of death was first recorded (1848–71) the reduction was 3.2 per cent''. These figures have since been confirmed for all western countries (see for example the decline in TB mortality in the USA) and for all then known infectious diseases. McKeown explained the decline in mortality from infectious diseases by an improved standard of living, particularly by better nutrition, and by better hygiene, and less by medical intervention. McKeown, who is considered as the father of social medicine, has advocated for many years, that with drugs and vaccines we may win the battle but will lose the war against Diseases of Poverty. Thereto, efforts and resources should be primarily directed toward improving the standard of living of people in low resource countries, and toward improving their environment by providing clean water, sanitation, better housing, education, safety and justice, and access to medical care. Particularly the work of Nobel laureates Robert Fogel, Robert W. Fogel (1993) and Angus Deaton (2015) have greatly contributed to the recent reappreciation of the McKeown thesis. A negative confirmation of the McKeown thesis was that increased pressure on wages by IMF loans to post-communist Eastern Europe were strongly associated with a rise in TB incidence, prevalence and mortality. In the United States there was dramatic reduction in tuberculosis cases by the 1970s. As early as the 1900s, public health campaigns were launched to educate people about the contagion. In later decades, posters, pamphlets and newspapers continued to inform people about the risk of contagion and methods to avoid it, including increasing public awareness about the importance of good hygiene. Though improved awareness of good hygiene practices reduced the number of cases, the situation was worse in the poor neighborhoods. Public clinics were set up to improve awareness and provide screenings. In Scotland, Dr Nora Wattie led the public health innovations both at local and national level. This resulted in sharp declines through the 1920s and 1930s.


Tuberculosis resurgence

Hopes that the disease could be completely eliminated were dashed in the 1980s with the rise of Antibiotic resistance, drug-resistant strains. Tuberculosis cases in Britain, numbering around 117,000 in 1913, had fallen to around 5,000 in 1987, but cases rose again, reaching 6,300 in 2000 and 7,600 cases in 2005. Due to the elimination of public health facilities in New York and the emergence of HIV, there was a resurgence of TB in the late 1980s. The number of patients failing to complete their course of drugs was high. New York had to cope with more than 20,000 TB patients with Multidrug resistance, multidrug-resistant strains (resistant to, at least, both rifampin and isoniazid). In response to the resurgence of tuberculosis, the World Health Organization issued a declaration of a global health emergency in 1993. Every year, nearly half a million new cases of multidrug-resistant tuberculosis (MDR-TB) are estimated to occur worldwide.Health ministers to accelerate efforts against drug-resistant TB
''World Health Organization''.


See also

* History of malaria * Timeline of global health * List of deaths due to tuberculosis


Notes


References


Books

* Abel, Emily K. ''Tuberculosis and the Politics of Exclusion : A History of Public Health and Migration to Los Angeles'' (Rutgers University Press 2007) * * Armus, Diego. ''The Ailing City: Health, Tuberculosis, and Culture in Buenos Aires, 1870–1950'' (2011) * * * * * * Bryder, Linda. ''Below the Magic Mountain: A Social History of Tuberculosis in Twentieth-Century Britain'' (1988), 298p. * * * * * * * * * * McMillen, Christian W. ''Discovering Tuberculosis: A Global History, 1900 to the Present'' (2014) * * * * * * * 446 + xxiii pages. * * * Smith, F. B. ''Retreat of Tuberculosis, 1850-1950'' (1988) 271p * * * Zumla, Alimuddin et al. eds. ''Tuberculosis: A Comprehensive Clinical Reference'' (Saunders, 2009) *


Older studies

* * * Unschuld, Paul U. and Hermann Tessenow (2011), ''Huang Di Nei Jing Su Wen: An Annotated Translation of Huang Di's Inner Classic – Basic Questions'', University of California Press. * * * Zhang Zhibin and Paul U. Unschuld (2014), ''Dictionary of the Ben cao gang mu, Volume 1: Chinese Historical Illness Terminology'', University of California Press.


Scholarly journals

* * * * * * * * * * * * * * * * * * * * * * * *


Conferences

* {{DEFAULTSORT:History of Tuberculosis Deaths from tuberculosis, Health in Africa History of medicine, tuberculosis History of pulmonology Tuberculosis, Tuberculosis