“Do not spit”: The history of tuberculosis, 4000 years on

“For every death from a zymotic [infectious] disease, some person should be hanged, and it would be only just to begin with the Prime Minister.” 

These were the words of a Melbourne city inspector in 1902, calling for spitting in public to be made illegal in an attempt to curb the spread of tuberculosis (TB). It marks the beginning of one of Australia’s earliest public health initiatives, in which the government, lacking an adequate cure, was called to consider options that promoted prevention.

2017-03-23 Tuberculosis Featured Photo

The 24th of March is World TB Day, serving to promote public awareness about a disease that continues to plague much of the world. The day marks the anniversary of Dr. Robert Koch’s isolation of mycobacterium tuberculosis, the bacterium that predominantly causes the disease. It presents us a timely occasion to reflect on some of the interesting moments in our historical confrontation with TB.

TB is one of the threads that has continually wound its way through human history, from as early as 2050 BCE to the current era. It was the subject of the ponderings of Hippocrates, the Greek physician who in addition to being credited with founding medicine was also the first to name the disease, which he called phthisis, meaning “to decay”.

It was the target of some of the earliest public health measures and continues to be the cause of immense suffering, responsible for the death of some 1.8 million people in 2015 alone.

 

In the 3rd Century BCE, the Roman playwright Plautus most charmingly described TB as “volatile vomiting of lung tissue”— and when one considers the rapid conglomeration of tissue formation (granulomas) in the lungs seen in TB, it seems his description is rather apt.

 

Tuberculosis 101

2017-03-23 Tuberculosis Photo 2TB is an infection primarily of the lungs, but can have secondary sites of infection in the bones, kidneys, skin, brain and heart. It is typically caused by mycobacterium tuberculosis, and far less commonly by mycobacterium bovis.

But whereas the former is airborne and spread between humans, the latter is first contracted by drinking unpasteurised, infected cow’s milk, after which it can be spread from human to human. But whilst Australia managed to eradicate M. bovis in 1997, this bacterium still persists globally.

Typically, TB causes a longstanding cough commonly productive of blood, as well as unexplained weight loss. Following first exposure, the bacteria often remain latent, only later reactivating in response to stress to the immune system.

For the most part, it is curable with a combination of four antibiotics taken over a period of around six months. But because it is often seen to be a disease of the third world, patients often experience stigma, and the protracted treatment regime and the possibility of missed doses can make it difficult for effective eradication.

Most notably, the recent emergence of multi-drug resistant strains of TB suggest it will continue to have a public presence into the near future.

 

Through the eyes of Hippocrates and Lord Byron

As important as it may be, for much of our history none of this was known. Back in ancient Greece, Hippocrates had preoccupied himself with explaining the mechanism by which TB spread. Noticing that it seemed to afflict entire families at a time, he suggested it might be a hereditary condition.

More than 2000 years later, it’s easy to smirk at some of Hippocrates’ aphorisms: “When a person has been cured of chronic haemorrhoids”, he said, “unless one be left, there is a danger…of tuberculosis supervening”.

To modern physicians, it’s clear there’s no causative link between haemorrhoids and TB. But in Hippocrates’ defence, he ultimately knew there was no cure, cautioning physicians to stay clear of patients in the terminal stages. Although we might also wonder if this is at odds with his suggestion that TB was hereditary.

But for all the grim reality, TB has also had its share of glamour and fame. Lord Byron, poet extraordinaire, reportedly said “I should like, I think, to die of consumption…because all the women would say ‘See that poor Byron—how interesting he looks in dying’”.

 

It would seem that throughout history, TB has been both romanticised and demonised, but has always remained at the centre of public discussion.

In the safety of a 21st century Western country, the “Do Not Spit” signs that still tile the walls of the Flinders Street Station underpass are perhaps mere curios. But they should also serve to remind us of the devastating impact that TB had on Melbourne only a short time ago, and the seriousness with which it continues to afflict much of the world today.

The views and opinions expressed in this article are those of the author and do not necessarily represent those of the Doctus Project.