A Memoir of the White Plague

J oseph Severn, friend of the English romance poet John Keats, sat by Keats’s side as he finally succumbed to tuberculosis. “The phlegm seemed boiling in his throat,” Severn wrote of his friend. “He gradually sunk into death — so quiet — that I still thought he slept.” An autopsy revealed that Keats’s “lungs were completely gone,” so thoroughly destroyed by the disease that doctors “could not conceive by what means he had lived these two months.”

The history of the pulmonary tuberculosis — a disease that killed John Keats and countless others since long before the birth of Christ — provides a sobering window into the depths of a public-health scare, one that contains lessons both cautionary and instructive as the United States confronts the Wuhan virus.

The etiology of the so-called White Plague was a mystery until 1882, when German physician Robert Koch discovered tubercle bacillus, the bacterium responsible for the disease, in a laboratory. Before the Koch’s breakthrough — and for several decades thereafter — many physicians referred to tuberculosis as “consumption” and to tubercular patients as “consumptives.” One telltale marker of the disease is the emaciated frames of its sufferers, so “consumption” was a useful — if crude — descriptor of the process of deterioration that befell many tubercular patients.

In 1840, more than 40 years before the discovery of tubercle bacillus, Dr. Bodington George of Edinburgh, one of the foremost tubercular physicians in 19th-century Britain, wrote a genre-defining essay detailing his interaction with “consumptive” patients. One man he describes came from a “consumptive family” and was “rather spare and slender.” His “fingernails were incurvated,” a possible manifestation of the digital clubbing that sometimes accompanies cases of pulmonary tuberculosis. “A feeling of suffocation affected” the man as his “pulse beat 140 in a minute.”

In the essay, George recommended the creation of what would later become known as the “sanatorium.” Sanatoria were asylum-like retreats, often located in high-altitude areas — the National Institutes of Health notes that “tuberculosis infection, disease and mortality are all less common at high than low altitude” — where treatments of rest, nutritious food, and sunlight were prescribed for patients. Tuberculosis is susceptible to ultraviolet light, so the prescription for exposure to sunlight was not altogether unfounded and was sufficient to cure some mild cases of TB.

Historian F. B. Smith said in 1988 that sanatoria “were medically supervised refuges from bad air, crowded households and the wear of industrial life, set in well-drained breezy but mild countryside.” Some were single-building facilities, while others were campus settings with cottages and hospital buildings. Many used some form of radial architecture, designed to maximize a patient’s exposure to sunlight. Connecticut’s Seaside Sanatorium, for instance, was built on a beach in Waterford, with imposing glass windows and patio beds for patients. A video of the since-demolished Western Maine Sanatorium shows much of the same, with patients sitting in radial buildings or atop a grassy knoll. Some appear frail; others appear likely to recover from their illness.

By 1936, more than 700 sanatoria dotted the American landscape. The National Tuberculosis Association, an organization headquartered in New York City, spawned affiliates in states and localities across the country in all 50 states, financed entirely by the sale of the group’s (apparently lucrative) Christmas ornaments. The NTA and its subsidiaries informed localities about best practices for preventing the spread of the disease, helped coordinate tubercular patients with sanatorium beds, and later facilitated their reentry into the community.

The mass exodus from the tubercular sanatoria in the 1950s and ’60s was facilitated by a number of medical breakthroughs. French scientists Albert Calmette and Camille Guérin discovered a vaccine in 1908 that, after 30 or so years of clinical trials, was proven to help immunize children from TB. The advent of the antibiotic streptomycin in 1945 helped eliminate the need for surgical remedies such as lobectomies and segmentectomies, which were often performed at sanatoria.

By the end of the 1960s, hardly any sanatoria remained in operation — at least as tubercular hospitals. We might look back on the sanatoria with some of F. B. Smith’s latent disdain, but as UCLA’s Dr. Robert Modlin suggested, speaking of TB, “our forefathers knew a lot more about it than we give them credit for.” Sunlight and rest at high altitude were not substitutes for the cures that followed, but they helped many milder patients return home healed of their illness.

The extent to which the sanatoria — rather than the medical advances that spelled their demise — were responsible for decreases in tubercular mortality is debatable. The most thorough analysis of mortality rates in Western countries from tuberculosis came from 20th-century demographer Thomas McKeown, who used centuries of birth and death records from England and Wales to construct mortality figures for tuberculosis over time. By the time Bodington George wrote his essay in 1840, the English death rate from the disease was nearly 3,000 per million. When Robert Koch discovered the tubercle bacillus in 1882, the mortality rate had fallen to just under 2,000 per million. When Calmette and Guérin’s vaccine reached Britain in the middle of the 1950s, the mortality rate had plummeted to less that 500 deaths per million. Those trends mirror the more limited data we have from the pre-1950s United States, declines that continued for several decades. By 2017, the CDC estimated that 515 people in America died from tuberculosis — a tragic figure, of course, but one that represents a staggering improvement from decades and centuries prior.

Through the National Tuberculosis Association and the three-pronged effort of private industry, the government, and charitable organizations working together in the fight against TB, the illness is nowhere near the killer it was at the start of the century. Perhaps “flattening the curve” is a less-than-apt phrase when speaking of a disease that spans generations, but, if nothing else, the story of the White Plague ought to provide a glimpse into the possibilities of public-health efforts.