Tuberculosis

## Overview

Tuberculosis (TB) is an infectious disease usually caused by Mycobacterium tuberculosis (MTB) bacteria. Tuberculosis generally affects the lungs, but can also affect other parts of the body. Most infections do not have symptoms, in which case it is known as latent tuberculosis. About 10% of latent infections progress to active disease which, if left untreated, kills about half of those affected. The classic symptoms of active TB are a chronic cough with blood-containing sputum, fever, night sweats, and weight loss. It was historically called "consumption" due to the weight loss. Infection of other organs can cause a wide range of symptoms.

Tuberculosis is spread through the air when people who have active TB in their lungs cough, spit, speak, or sneeze. People with latent TB do not spread the disease. Active infection occurs more often in people with HIV/AIDS and in those who smoke. Diagnosis of active TB is based on chest X-rays, as well as microscopic examination and culture of body fluids. Diagnosis of latent TB relies on the tuberculin skin test (TST) or blood tests.

Prevention of TB involves screening those at high risk, early detection and treatment of cases, and vaccination with the bacillus Calmette-Guérin (BCG) vaccine. Those at high risk include household, workplace, and social contacts of people with active TB. Treatment requires the use of multiple antibiotics over a long period of time. Antibiotic resistance is a growing problem with increasing rates of multiple drug-resistant tuberculosis (MDR-TB) and extensively drug-resistant tuberculosis (XDR-TB).

Presently, one-quarter of the world's population is thought to be infected with TB. New infections occur in about 1% of the population each year. In 2017, there were more than 10 million cases of active TB which resulted in 1.6 million deaths. This makes it the number one cause of death from an infectious disease. More than 95% of deaths occurred in developing countries, and more than 50% in India, China, Indonesia, Pakistan, and the Philippines. The number of new cases each year has decreased since 2000. About 80% of people in many Asian and African countries test positive while 5–10% of people in the United States population test positive by the tuberculin test. Tuberculosis has been present in humans since ancient times.

## History

Tuberculosis has existed since antiquity The oldest unambiguously detected M. tuberculosis gives evidence of the disease in the remains of bison in Wyoming dated to around 17,000 years ago. However, whether tuberculosis originated in bovines, then transferred to humans, or whether both bovine and human tuberculosis diverged from a common ancestor, remains unclear. A comparison of the genes of M. tuberculosis complex (MTBC) in humans to MTBC in animals suggests humans did not acquire MTBC from animals during animal domestication, as researchers previously believed. Both strains of the tuberculosis bacteria share a common ancestor, which could have infected humans even before the Neolithic Revolution. Skeletal remains show some prehistoric humans (4000 BC) had TB, and researchers have found tubercular decay in the spines of Egyptian mummies dating from 3000–2400 BC. Genetic studies suggest the presence of TB in the Americas from about 100 AD.

Before the Industrial Revolution, folklore often associated tuberculosis with vampires. When one member of a family died from the disease, the other infected members would lose their health slowly. People believed this was caused by the original person with TB draining the life from the other family members.

Although Richard Morton established the pulmonary form associated with tubercles as a pathology in 1689, due to the variety of its symptoms, TB was not identified as a single disease until the 1820s. J. L. Schönlein coined the name "tuberculosis" in 1839. Between 1838 and 1845, Dr. John Croghan, the owner of Mammoth Cave in Kentucky from 1839 onwards, brought a number of people with tuberculosis into the cave in the hope of curing the disease with the constant temperature and purity of the cave air; each died within a year. Hermann Brehmer opened the first TB sanatorium in 1859 in Görbersdorf (now Sokołowsko) in Silesia.

Robert Koch identified and described the bacillus causing tuberculosis, M. tuberculosis, on 24 March 1882. He received the Nobel Prize in physiology or medicine in 1905 for this discovery. Koch did not believe the cattle and human tuberculosis diseases were similar, which delayed the recognition of infected milk as a source of infection. During the first half of the 1900s the risk of transmission from this source was dramatically reduced after the application of the pasteurization process. Koch announced a glycerine extract of the tubercle bacilli as a "remedy" for tuberculosis in 1890, calling it "tuberculin". While it was not effective, it was later successfully adapted as a screening test for the presence of pre-symptomatic tuberculosis. World Tuberculosis Day is marked on 24 March each year, the anniversary of Koch's original scientific announcement.

Albert Calmette and Camille Guérin achieved the first genuine success in immunization against tuberculosis in 1906, using attenuated bovine-strain tuberculosis. It was called bacille Calmette–Guérin (BCG). The BCG vaccine was first used on humans in 1921 in France, but achieved widespread acceptance in the US, Great Britain, and Germany only after World War II.

Tuberculosis caused widespread public concern in the 19th and early 20th centuries as the disease became common among the urban poor. In 1815 one in four deaths in England was due to "consumption". By 1918, TB still caused one in six deaths in France. After TB was determined to be contagious, in the 1880s, it was put on a notifiable-disease list in Britain; campaigns started to stop people from spitting in public places, and the infected poor were "encouraged" to enter sanatoria that resembled prisons (the sanatoria for the middle and upper classes offered excellent care and constant medical attention). Whatever the benefits of the "fresh air" and labor in the sanatoria, even under the best conditions, 50% of those who entered died within five years (c. 1916). When the Medical Research Council formed in Britain in 1913, it initially focused on tuberculosis research.

In Europe, rates of tuberculosis began to rise in the early 1600s to a peak level in the 1800s, when it caused nearly 25% of all deaths. By the 1950s mortality in Europe had decreased about 90%. Improvements in sanitation, vaccination, and other public-health measures began significantly reducing rates of tuberculosis even before the arrival of streptomycin and other antibiotics, although the disease remained a significant threat. In 1946 the development of the antibiotic streptomycin made effective treatment and cure of TB a reality. Prior to the introduction of this medication, the only treatment was surgical intervention, including the "pneumothorax technique", which involved collapsing an infected lung to "rest" it and to allow tuberculous lesions to heal.

Because of the emergence of MDR-TB, surgery has been re-introduced for certain cases of TB infections. It involves the removal of infected chest cavities ("bullae") in the lungs to reduce the number of bacteria and to increase exposure of the remaining bacteria to antibiotics in the bloodstream. Hopes of completely eliminating TB ended with the rise of drug-resistant strains in the 1980s. The subsequent resurgence of tuberculosis resulted in the declaration of a global health emergency by the World Health Organization in 1993.

### Aeras

If multiple family members began to fall ill after a consumption death and vampirism was expected, communities took a nontraditional approach to treating the disease, beginning with exhuming the body and removing its heart. If the heart contained “fresh” blood (an effect of decomposition, but believed to be blood the vampire had sucked out of the living), the heart would be burned and the ashes fed to sick family members as a cure, or a stake would be driven through the heart, a practice still associated with vampire myths today.

Symptoms of tuberculosis and the appearance of a decomposing body also contributed to the connection between the illness and the vampire myth. Common tuberculosis symptoms, including red, swollen, light-sensitive eyes, pale skin, low body heat, a weak heartbeat, and coughing up blood, as well the breakdown of lung tissue during and after death from tuberculosis, which caused the lips of corpses to appear bloody, all aligned with common beliefs about vampires.

Evidence sustains the connection between tuberculosis and vampire beliefs: of 12 reported vampire incidents in 18th-19th century New England, the “vampire” and its relatives reportedly died of consumption in 11 of the cases. The poor nutrition and unsanitary and crowded living conditions in New England during this time period would also have provided an ideal environment for the transmission of the disease.

Tuberculosis diagnosis, treatment, and prevention options have luckily come a long way since the vampire-hunting days of the disease. While traditional antibiotics are becoming less effective in the face of multi-drug-resistant and extensively-drug-resistant tuberculosis, a robust global pipeline of tuberculosis vaccine candidates will hopefully soon mean that tuberculosis, like the belief in vampires causing consumption, will be a thing of the past.

http://www.aeras.org/blog/tuberculosis-and-the-vampire-myth

### Mental Floss

Tuberculosis was entrenched in the Americas even before the United States existed as a country. President George Washington himself likely fought the disease after contracting it from his brother—ironically, on a trip taken to Barbados in an attempt to treat Lawrence Washington’s illness, according to medical historian Howard Markel of the University of Michigan.

Washington wasn’t alone. Other notable American sufferers of tuberculosis included James Monroe, Ralph Waldo Emerson, Henry David Thoreau, Washington Irving, John “Doc” Holliday, and Helen Hunt Jackson.

In 1786, when health officials first began recording mortality rates connected to the deadly infection, Massachusetts alone recorded 300 consumption deaths for every 100,000 residents. Between that year and 1800, tuberculosis killed 2 percent of New England’s population. In many cases, living in the same home was enough for the disease to spread throughout an entire family. It was estimated that anywhere from 70 to 90 percent of the U.S. population had latent or active tuberculosis infections.

Today, most people understand that tuberculosis is spread through the air, by breathing in bacteria coughed up by people with active infections in their lungs or throats. There are vaccines, though they’re rarely used in the U.S., and treatments for those who contract active tuberculosis infections.

In the 1800s, however, germ theory was only just beginning to gain supporters among the medical community. Doctors were still arguing over the causes of tuberculosis in 1895, and treatment mainly consisted of leaving large cities like New York and Boston, where the disease ran rampant, for places like Pasadena, California and Colorado Springs, where the climate was supposed to help ease the symptoms. Until the rise of the sanatoria movement (basically, rest-oriented treatment centers) at the end of the 19th century, few medical treatments worked. Even sanatoria only helped some patients.

As tuberculosis spread from the cities out into the countryside, people didn’t know what caused it or how to stop it. In some New England towns, such as Lynn, Massachusetts, it was the leading cause of death, Bell says. Entire families were wiped out, and there didn’t seem to be any rhyme or reason to who caught the illness.

It was not a pleasant way to die. Symptoms included wasting, night sweats, and fatigue, and a persistent cough that sometimes produced white phlegm or foamy blood. Occasionally, the cough turned into hemorrhaging. Those who caught it could not know if they would eventually recover, painfully waste away over the course of years, or die in a matter of months from the “galloping” form of the disease. If they did recover, there was always the fear that the illness would return.

“Cholera, plague, smallpox, yellow fever, influenza, and measles were fast-burning epidemics that appeared, killed, and then went dormant as immunities kicked in,” Bell says. Tuberculosis did not. It was an unrelenting fact of life in the 1800s. With no other explanations, people turned to the supernatural to understand the epidemic, and to offer hope of a cure.

Enter the vampire.

http://mentalfloss.com/article/87985/how-tuberculosis-inspired-19th-century-new-england-vampire-panic

### Smithsonian

In the late 19th century, Exeter, like much of agrarian New England, was even more sparsely populated than usual. Civil War casualties had taken their toll on the community, and the new railroads and the promise of richer land to the west lured young men away. By 1892, the year Lena died, Exeter’s population had dipped to just 961, from a high of more than 2,500 in 1820. Farms were abandoned, many of them later to be seized and burned by the government. “Some sections looked like a ghost town,” Reynolds-Boothroyd says.

And tuberculosis was harrying the remaining families. “Consumption,” as it was called, had started to plague New England in the 1730s, a few decades before the first known vampire scares. By the 1800s, when the scares were at their height, the disease was the leading cause of mortality throughout the Northeast, responsible for almost a quarter of all deaths. It was a terrible end, often drawn out over years: a skyrocketing fever, a hacking, bloody cough and a visible wasting away of the body. “The emaciated figure strikes one with terror,” reads one 18th-century description, “the forehead covered with drops of sweat; the cheeks painted with a livid crimson, the eyes sunk...the breath offensive, quick and laborious, and the cough so incessant as to scarce allow the wretched sufferer time to tell his complaints.” Indeed, Bell says, symptoms “progressed in such a way that it seemed like something was draining the life and blood out of somebody.”

People dreaded the disease without understanding it. Though Robert Koch had identified the tuberculosis bac­terium in 1882, news of the discovery did not penetrate rural areas for some time, and even if it had, drug treatments wouldn’t become available until the 1940s. The year Lena died, one physician blamed tuberculosis on “drunkenness, and want among the poor.” Nineteenth-century cures included drinking brown sugar dissolved in water and frequent horseback riding. “If they were being honest,” Bell says, “the medical establishment would have said, ‘There’s nothing we can do, and it’s in the hands of God.’”

But Lena Brown’s exhumation made news. First, a reporter from the Providence Journal witnessed her unearthing. Then a well-known anthropologist named George Stetson traveled to Rhode Island to probe “the barbaric superstition” in the surrounding area.

Published in the venerable American Anthropologist journal, Stetson’s account of New England’s vampires made waves throughout the world. Before long, even members of the foreign press were offering various explanations for the phenomenon: Perhaps the “neurotic” modern novel was driving the New England madness, or maybe shrewd local farmers had simply been pulling Stetson’s leg. A writer for the London Post declared that whatever forces drove the “Yankee vampire,” it was an American problem and most certainly not the product of a British folk tradition (even though many families in the area could trace their lineage directly back to England). In the Boston Daily Globe, a writer went so far as to suggest that “perhaps the frequent intermarriage of families in these back country districts may partially account for some of their characteristics.”

One 1896 New York World clipping even found its way into the papers of a London stage manager and aspiring novelist named Bram Stoker, whose theater company was touring the United States that same year. His gothic masterpiece, Dracula, was published in 1897. Some scholars have said that there wasn’t enough time for the news accounts to have influenced the Dracula manuscript. Yet others see Lena in the character of Lucy (her very name a tempting amalgam of “Lena” and “Mercy”), a consumptive-seeming teenage girl turned vampire, who is exhumed in one of the novel’s most memorable scenes. Fascinatingly, a medical doctor presides over Lucy’s disinterment, just as one oversaw Lena’s.

https://www.smithsonianmag.com/history/the-great-new-england-vampire-panic-36482878/

### Consumption and vampires

Prescientific cultures: communicable diseases prior to the germ theory
“The Vampire is consumption in human form, embodying an evil that slowly and secretly drains the life from its victims.”

“For as long as what caused tuberculosis was not understood… tuberculosis was thought to be an insidious, implacable theft of a life…Any disease that is treated as a mystery and acute enough to be feared will be felt to be morally…contagious.”

– Susan Sontag

Prior to the Germ Theory, from the time of Aristotle, miasmas – or currents of contaminated air circulated by winds—were considered the cause of communicable diseases.7 As a result, continued connections between consumption and the vampire myth persisted into the late Nineteenth Century.

“Mercy died, apparently of tuberculosis, in January 1892… Mercy was a vampire…Mercy’s brother Edwin was a strapping young man of 18…in 1891 Mercy and Edwin both became ill… the boy went off to Colorado, where he recovered. His sister (Mercy) eventually was carried to her grave by the illness… Edwin returned still in weak health…why was such a strong man’s life draining away? Why had the same thing happened to Mercy only a few months before…nothing less terrible than a vampire was sucking their children’s blood and taking their lives with it…to their infinite horror, Mercy’s body, which had blood and seemed unnaturally preserved, with color still in the cheeks…(They) removed the corpse’s heart and burned it on a rock.”

Consumption – the captain of all these men of death—was chosen and persisted as a metaphor for vampirism. Charles Dickens wrote, that for individuals with tuberculosis, “life and death are so strangely blended that death takes the “glow and hue of life, and life the gaunt and grisly form of death” (Nicholas Nickleby). Dickens and others who witnessed victims of consumption—precariously hovering between life and death—recognized the stigma:

“The emaciated figure strikes one with terror; the forehead covered with drops of sweat; the cheeks painted with a livid crimson, the eyes sunk; the little fat that raised them in their orbits entirely wasted; the pulse quick and tremulous; the nails long, bending over the ends of the fingers; the palms of the hands dry and painfully hot to the touch; the breath offensive, quick and laborious, and the cough so incessant as scarce to allow the wretched sufferer time to tell his complaints.”

Science, ascendant in the late Nineteenth, early twentieth century identified Mycobacterium Tuberculosis as the agent of tuberculosis. Science also shed light on bodily decomposition after death. The cure of tuberculosis would follow and the myth and metaphors surrounding tuberculosis would disappear. However, despite science, for Susan Sonntag, other diseases—such as cancer and AIDS—would resuscitate illness metaphors.

The contemporary vampire craze does not do justice the authentic history of the vampire. As healthcare professionals, it is critical to understand humanity’s millennially long struggle to place illness and death into a plausible perspective. This effort is an essential part of medicine qua humanism. As Tennyson also said, from his personal theistic worldview perspective, “Thou madest man, he knows not why, he thinks he was not made to die.”

https://hekint.org/2017/03/04/consumption-and-vampires-metaphor-and-myth-before-science/

### Phthisis, consumption and the White Plague

Tuberculosis is an infection with Mycobacterium tuberculosis which can occur in any organ of the body but is most well known in the lung. It has been a scourge throughout known history and may have killed more persons than any other microbial
pathogen. Paleopathological evidence dates back to 8000 BCE and evidence of bony tuberculosis has been found dating from the Neolithic period in 5800 BCE and in Egyptian mummies dating to 2400 BCE.

Tuberculosis was also known as phthisis and consumption from Hippocrates through to the 18th century, the white death and the great white plague during the 19th century, and other names which evoked the despair and horror of the disease such as the robber of youth6, the Captain of all these men of Death, the graveyard cough8, and the King’s-Evill. During the 18th and 19th centuries tuberculosis was epidemic in Europe and caused millions of deaths, particularly in the poorer classes of society. Tuberculosis declined after the late 19th century but remained a major public health issue as it still is today.

Tuberculosis is an important disease for the military. During both World War I and World War II in the US Army, tuberculosis was the leading cause of discharge. Annual incidence of tuberculosis in the military of Western countries is very low, however in the last several decades microepidemics have occurred in small close knit units on US and British Naval warships and land based units deployed overseas. Living and working in close quarters and overseas deployment to tuberculosis-endemic areas of the world such as Afghanistan, Iraq and South-East Asia remain significant risk factors for tuberculosis infection in military personnel, particularly multidrug resistant tuberculosis.

The imagery of the consumptive was also used by the writers of popular fiction of the 19th century who began the literary tradition of vampirism to describe vampires and their victims. Consequently it was sometimes thought, especially in areas of the world where such folklore abound such as New England in America and Yorkshire in northern Britain, that people seen to be suffering from what were actually symptoms of tuberculosis, the wasting and extreme pallor, were victims of vampires or were vampires themselves.

There were certain social conditions that were intimately associated with the disease, linked to the industrial revolution at the time - poverty, malnutrition, and overcrowding. Conditions for the working classes were extremely poor.8 In 1838 and 1839 in England between a quarter and a third of tradesmen and labourers died from tuberculosis compared to a sixth of “gentlemen”

### Vampires and Death

During the 18th and 19th centuries, New England was in the grip of a terrible tuberculosis epidemic. During the 19th century, this disease was the leading cause of death in the Eastern United States, accounting for nearly 25 percent of all deaths. Despite an abundance of cures offered by an eclectic mix of practitioners, a diagnosis of consumption—as pulmonary tuberculosis was then called—was the equivalent of a death sentence. Not willing to simply watch as, one after another, their family members died, some New Englanders resorted to an old folk remedy whose roots surely must rest in Europe. Called vampirism by outsiders (a term that may never have been used by those within the communities themselves) this remedy required exhuming the bodies of deceased relatives and checking them for “unnatural” signs, such as “fresh” blood in the heart. The implicit belief was that one of the relatives was not completely dead and was maintaining some semblance of a life by draining the vital force from living relatives.

All of the more than 20 cases documented in New England occurred in areas outside of the Puritan heartland of Massachusetts and contiguous Connecticut—“fringe” areas that were Separatist, Tolerant, or unspecified in terms of religious affiliation. Perhaps surprisingly, from 85 to 90 percent of white New Englanders of this era were “unchurched,” many practicing various hybrid religions that have been classified as “folk” in the sense that they were unofficial combinations of Christian beliefs and various folk practices of the kind often disparagingly referred to as “superstitions.” Interpreting the vampire practice through diverse strands of evidence, including eye witness accounts, family stories, local legends, newspaper articles, local histories, town records, journal entries, unpublished correspondence, genealogies, and even actual human remains reveals that to many New Englanders the border between life and death was indeed far more fragile and ill defined than histories that are based solely on conventional sources have suggested.

https://anthrosource.onlinelibrary.wiley.com/doi/abs/10.1525/ahu.2006.31.2.124

### The Social Impact of the Misconceptions Surrounding Tuberculosis

While some romanticized tuberculosis, others feared the disease. By 1800
in the New England area of the United States, twenty-five percent of deaths
were caused by tuberculosis. Throughout New England, rumors of vampires
causing tuberculosis spread. After the death of a tuberculosis victim, the family
of the deceased would often start expressing symptoms of the disease as well.
Friends and neighbors accused the deceased of being a vampire who was
sucking the life out of his family, which was why they were exhibiting signs of
illness.

The best-known case of “vampirism” in the United States occurred in 1892
in the small town of Exeter, Rhode Island. By the time George Brown’s son
Edwin fell ill with tuberculosis, three members of the family had already died
of the disease. While George Brown was skeptical about vampires causing his
son’s illness, his neighbors had no doubt. Neighbors called for the death of the
vampire, and rising pressure forced Brown to exhume the bodies of his
deceased family members and burn the heart of his daughter. The ashes were
fed to Edwin, who died soon after. Brown’s story showed that while not all
New Englanders believed in vampires, peer pressure forced many to partake
in the vampire furor.

Most of the behavior in response to vampirism occurred prior to Koch’s
discovery of the tuberculosis bacteria. Around the second half of the 19th
century, germ theory and contagion had gained acceptance by the public.
However, the vampire belief persisted in rural areas. The rural towns of New
England tended to be fairly isolated and education was not available for all.
This prevented scientific ideas, such as contagion, from reaching the people of
the New England area. It also allowed for superstitious beliefs and folklore to
continue even after the discovery of the tubercle bacillus.

People fear what they cannot see, and fear was a large contributor to the
vampire panic of the area. Prior to the discovery of tuberculosis’s cause, people
were frantic to find something to attribute the disease to. They were even more
desperate for a cure. The people of New England decided that it was better to
exhume, burn, and sometimes even eat the bodies of vampires rather than
watch their loved ones die. Even after Koch’s discovery in 1882, there was
still no cure for tuberculosis, which allowed the vampire myth to persist.
Throughout history, untimely deaths have been seen as unnatural, and people
of many cultures have feared the return of the dead to haunt the living. This
tied the untimely deaths caused by tuberculosis to vampires in the minds of
New Englanders. In addition, the symptoms of the disease were also linked to
vampirism. Consumptives suffered more at night, resulting in them being
awake at night. They also had a pale, deathlike pallor and sometimes blood in their mouths (caused by hemoptysis). Fear and folklore had driven the people
of New England to conclude vampires were responsible for their suffering. As
hysteria has been known to do, it brought out irrational behaviors in New
England that seem almost backwards given the time period. In 1892, the
Providence Journal referred to the Browns’ story as evidence that “civilization”
was being threatened by “survivals of primitive thought.” Upon reading of a
family who burned a “vampire,” Henry David Thoreau wrote, “The savage in
man is never quite eradicated.” While their actions were deemed “primitive”
by the rest of the Western world, the people of New England felt as if they had
no choice but to burn the bodies of the deceased, as no other cure had been
discovered. Fearing for their lives, some New Englanders were willing to do
whatever it took to survive.

https://ir.uiowa.edu/iowa-historical-review/vol7/iss1/4/

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