Miriam Goldstein

Fall 2013

A Mere Skeleton Covered with Skin: The Changing Meanings of Tuberculosis, 1785-1945
Tuberculosis should have been a unifying disease. During the long nineteenth century,
consumptives of all races, religions, classes, and genders suffered from the same basic
symptoms, and unfortunately, usually the same devastating end. By 1900, increasing
urbanization which included the coming together of masses of people and their germs alike
had permitted the disease to account for 10.4 percent of all deaths in the United States.1 There
was no one who was not affected in some way, whether through his or her own demise or that of
a family member or friend. Although the exact manifestation of tuberculosis varied from person
to person,2 each victim had endured for the most part the same vague fatigue from trifling
exertions of the body or mind as the disease began its long-winded course, the same
unremarkable fever and tickling of the throat that would eventually lead to that telltale persistent
cough that was sometimes pus-filled, sometimes bloody, sometimes both. From there things only
went further downhill as the body literally began wasting away, becoming nothing more than a
mere skeleton covered with skin, prepared for a certain end. 3 Indeed, it was recognized early on
how little this disease is under the power of medicine, how, once it was contracted, death was
almost inevitable.4 Because no effective cure for tuberculosis was discovered until the middle of
the twentieth century,5 physicians spent much of the preceding time invested in the study of
susceptibility. If they could figure out who might be especially likely to fall ill, they had a chance
of stopping the disease before it could ever take hold. This attitude had become particularly
prevalent by the mid-nineteenth century rise of public health, when prevention plans began to
reach beyond the level of the individual to form widespread, community-oriented programs. 6 In
fact, these susceptibility studies rarely focused on how the disease might affect individuals,
instead choosing to determine what categories of people whether based on body structure,
complexion, gender, race, social status, or something else entirely were most vulnerable. At its
best, from the eighteenth to the earlier part of the twentieth century, this tendency toward
classification spawned a fanciful image of tuberculosis that was able to garner increased
sympathy for the sufferers. At its worst, especially by sometime in the twentieth century,
increased awareness of the diseases prevalence among blacks helped foster the importation of
racist notions already prevalent in the greater community into the scientific domain. In the
end, determining which groups of people tuberculosis was inclined to strike probably had little
effect on reducing the spread of the disease. Instead, it only increased the spread of something
almost as injurious: the division of a people who should have been united against their common
enemy, tuberculosis.
Shaping all understanding of tuberculosiss causes was the notion put forth by earlynineteenth century physician John Armstrong, among others, that two circumstances are
necessary for the production of the true phthisis: first, a predisposition in the lungs to the
1

H.W. Hetherington and Fannie Eshleman, Nursing in Prevention and Control of Tuberculosis (New York: G.P.
Putnams Sons, 1945), 7.
2
Ibid., 20-25.
3
Francis Bowes Sayre, An Inaugural Dissertation on the Causes Which Produce a Predisposition to Phthisis
Pulmonalis (Trenton: Isaac Collins, 1790), 9-10.
4
Thomas Reid, An Essay on the Nature and Cure of the Phthisis Pulmonalis (Philadelphia: Joseph Crukshank,
1785), 37.
5
Robert Koch and Tuberculosis, accessed November 17, 2013,
http://www.nobelprize.org/educational/medicine/tuberculosis/readmore.html.
6
John Harley Warner and Janet A. Tighe, Major Problems in the History of American Medicine and Public Health
(Boston: Wadsworth, 2001), 159.

Miriam Goldstein

Fall 2013

tubercular action, and secondly, the concurrence of an occasional cause to excite that action.7 It
is the former half of this idea that drove the search for innate dispositions to tuberculosis within
certain populations, and the latter half that eventually promoted increased investment in the
prevention of those behavioral or environmental causes that were deemed avoidable. This
predisposition to the disease was often conceived of at least until sometime in the twentieth
century as a hereditary susceptibility that was inherited from consumptive parents.8 It was
already understood that members of the same family very generally bear a resemblance to each
other in personal configuration,9 so it was not difficult to extend this framework to include a
similarity in disease susceptibility as well. In fact, some of the factors believed to make one
especially vulnerable to contracting tuberculosis were physical in nature. One such example that
was particularly resistant to change over the centuries is that of body morphology. From the
eighteenth century into the nineteenth, one can observe the same example of the thin, narrowchest and the long, delicate limbs.10 A mid-nineteenth century physician explained why this build
can provoke tuberculosis: The diathesis here, is mainly dependent upon the insufficient capacity
of the chest through want of breath.11 But body type was not the only physical feature said to
affect ones likelihood of succumbing to the disease. Light hair, blue eyes12 and a brilliant
whiteness of skin13 are consistently mentioned in sources throughout the eighteenth and
nineteenth centuries as features common to consumptives.14 A particularly striking description of
the tuberculosis sufferers typical appearance can be found in the writings of nineteenth-century
physician William MDowell: The skin is remarkably thin, fair and delicate, the hair light, the
countenance full and pasty, the upper lip tumid, eyes blue, with large pupils, and lids fringed
with long lashes, the expression serene and placid, the mind unusually intelligent, and the
nervous system highly excitable.15
In these physical descriptions of tuberculosis victims, two things appear to be happening.
First of all, the sufferers are given a waiflike, almost supernatural image that had the capacity to
garner substantial interest and sympathy.16 Louis Leroy, a physician and Vanderbilt professor in
the early twentieth century, even describes how artists Botticelli and Rossetti among them
would employ consumptive models for their works because they had not the splendid natural
beauty of health but an appealing sadness to them.17 All of these models were females, and
because women, especially the most beautiful and elegant of the sex, were professed to be
more likely to contract tuberculosis, this only added further to the sense that it was a disease of
7

John Armstrong, Facts, Observations, and Practical Illustrations, Relative to Puerperal Fever, Scarlet Fever,
Pulmonary Consumption, and Measles (Hartford: O.D. Cooke & Sons, 1823), 144.
8
William Cornell, Consumption Forestalled and Prevented (Boston: French, 1846), 9-10.
9
William MDowell, A Demonstration of the Curability of Pulmonary Consumption, in All Its Stages: Comprising
an Inquiry into the Nature, Causes, Symptoms, Treatment, and Prevention of Tuberculosis Diseases in General
(Louisville: Prentice and Weissinger, 1843), 79.
10
Ibid., 2-3.; Francis Bowes Sayre, An Inaugural Dissertation on the Causes Which Produce a Predisposition to
Phthisis Pulmonalis, 12.
11
Ibid., 217.
12
Cornell, Consumption Forestalled and Prevented, 10-11.
13
MDowell, A Demonstration of the Curability of Pulmonary Consumption, 80.
14
Armstrong, Facts, Observations, and Practical Illustrations, Relative to Puerperal Fever, Scarlet Fever,
Pulmonary Consumption, and Measles, 98-100.; Reid, An Essay on the Nature and Cure of the Phthisis Pulmonalis,
2.; Sayre, An Inaugural Dissertation on the Causes Which Produce a Predisposition to Phthisis Pulmonalis, 12.
15
MDowell, A Demonstration of the Curability of Pulmonary Consumption, 217-218.
16
Cornell, Consumption Forestalled and Prevented, 12.
17
Louis Leroy, Pulmonary Tuberculosis (Nashville: Foster, Webb & Parkes, 1910), 11-12.

Miriam Goldstein

Fall 2013

the delicate.18 Secondly, the characteristically Anglo-Saxon features that were said to make the
tuberculosis victim from the best, as well as the loveliest part of creation,19 convey something
about societys preference for those of Western European ancestry.
Tuberculosis, during the eighteenth and nineteenth centuries, was ultimately deemed a
disease of civilization. While sickness may have otherwise been associated with backwardness or
low social status, with so many of the worlds most revered souls coming down with this
particular illness, tuberculosis had to be framed as something that preferred to feed on polite
society. Attempts were made to explain why the different stages of society influence this
disease [so] much.20 Eighteenth-century physician Francis Bowes Sayre brings up the example
of the Native Americans, suggesting that tuberculosis is almost never found among them because
the savages constant exposure to such physically grueling primitive practices as hunting and
outdoor living makes his body firm and easily able to fend off such a malady. A mark of
civilization, on the other hand, is leisure. In civilized countries, people tend to lead more
sedentary lives, producing a weakness of the body that makes them especially susceptible to
tuberculosis.21 Whatever strength of mind or creative talents the diseases refined victims may
have possessed did not matter. Their soft souls allowed tuberculosis to easily carry them away
from this earth.
It was not until the twentieth century, after knowledge of Kochs discovery of the
tubercle bacillus in 1882 had had time to take hold,22 that tuberculosis lost its romanticized
image and began to be looked at as an infectious disease. The rise of the germ theory of disease
precipitated tuberculosiss fall into the domain of dirty diseases: those more commonly
contracted by people who were of the lower class or otherwise lacking in so-called moral
stamina.23 Gone were the sentimental trappings of yore. More so now than ever, an emphasis
was placed on behavior, rather than predestined causes of tuberculosis. Unfortunately, that did
not mean that unfounded assumptions about certain groups of people became any less frequent;
in fact, far from it. Now, instead of blaming the contraction of tuberculosis on unalterable
physical features, it was attributed to an innate inability to avoid the undermining influences
and resist the allurements with which our civilization surrounds them.24 And because it was the
groups behaviors which could inevitably affect others that were deemed problematic and
disease-causing, a level of increased fear towards the people in these groups could be generated.
At its most extreme, anxiety about what these inferior groups were doing to society as a whole
led to the enactment of eugenic policies, aimed at solving the problem once and for all.25
One group that was marked as particularly likely to acquire tuberculosis because of some
fault in their behavioral practices was the black population especially in the United States,
where racist sentiment and fear of the other was at its height.26 The more than doubled
tuberculosis death rate for blacks compared to whites was attributed to the former groups
tendency to refuse prolonged institutional care and return to family and friends, where

18

Reid, An Essay on the Nature and Cure of the Phthisis Pulmonalis, 3.

Cornell, Consumption Forestalled and Prevented, 12-13.
20
Sayre, An Inaugural Dissertation on the Causes Which Produce a Predisposition to Phthisis Pulmonalis, 12.
21
Ibid., 13-14.
22
Warner and Tighe, Major Problems in the History of American Medicine and Public Health, 235.
23
Leroy, Pulmonary Tuberculosis, 14.
24
Ibid.
25
Warner and Tighe, Major Problems in the History of American Medicine and Public Health, 263.
26
Ibid., 406.
19

Miriam Goldstein

Fall 2013

gregarious tendencies, overcrowding, and failure to understand the importance of prophylactic

measures may make them an unusually dangerous foci from which disease may be spread.27
The case of the Jews (although, at least in some circles, a hardly less despised group than
the blacks) sometimes acted as a foil to the black situation. The Jews served as an example of a
people so stereotypically overprotective and well-fed as to make tuberculosis a rarity within their
ranks. The strength of the family instinct, the greater care which is given to the young, and
the anxious watching of the children by both the parents and their community were noted as
features that made the Jew healthier than his neighbor in all senses, including the ability to ward
off tuberculosis.28 Another factor said to prevent tuberculosis among Jews was their superior
nutrition when compared to the general population. Because Jews for the most part did not drink
alcohol, they were able to spend more of their earnings on food. More money invested meant
both greater quantity and better quality, which in turn meant better nutrition. The contrast in the
cases of the African-American and the Jew affirms the change from a focus on innate traits to a
focus on the acquired causes of disease that took place between the nineteenth and twentieth
centuries: it was no longer just about who a group was, but what it did, that affected the
likelihood of falling prey to tuberculosis.
Although the idea of acquired tuberculosis susceptibility could be (and often was)
manipulated towards negative ends especially when applied to specific populations of people
it must also be recognized that there was some truth to the notion that certain extrinsic conditions
heightened ones likelihood of acquiring the disease. Indeed, it was probably not the discovery of
a cure for tuberculosis but the improvement in living conditions29 that ultimately led to the rapid
decline in tuberculosis cases that occurred during the first half of the twentieth century.30
Because of the notion that certain populations might be more prone to the disease than others,
special programs were sometimes put in place to address the specific prevention needs of these
individual groups. For example, ones occupation was often taken as a measure of how
susceptible to tuberculosis one might be.31 With this in mind, pleas were made to the overseers of
factories where conditions for the contraction of tuberculosis were just right to pay strict
attention to [the factory workers] morals and comforts, to the ventilation of the apartments,
where they labour, and by the erection of baths to promote personal cleanliness; and even
expedients might be invented to guard them in great measure against the inhalation of those
noxious particles or effluvia, likely to subject them to consumption, or to any other distemper.32
This was not the only public health measure spurred on by the increased twentiethcentury focus on how environmental conditions can affect certain groups. Low-income families
were frequently cited as strongholds onto which tuberculosis could latch and never let go. Just as
with blacks, it was believed that the poor lacked basic hygiene skills that could help with disease
prevention. However, unlike in the case of the former, it was believed that this latter group could
alter their way of life, if only they had the proper instruction. With this in mind, nurses were sent

27

Hetherington and Eshleman, Nursing in Prevention and Control of Tuberculosis, 9-11.

Tuberculosis Among Jews, The British Medical Journal, 1908, 1, 1001.
29
Elaine G. Breslaw, Lotions, Potions, Pills, and Magic: Health Care in Early America (New York: New York
University, 2012), 194.
30
Hetherington and Eshleman, Nursing in Prevention and Control of Tuberculosis, 6.
31
Ibid., 11.
32
Armstrong, Facts, Observations, and Practical Illustrations, Relative to Puerperal Fever, Scarlet Fever,
Pulmonary Consumption, and Measles, 117-118.
28

Miriam Goldstein

Fall 2013

to intervene, educating the poor on prevention strategies with the goal of halting the spread of
tuberculosis within the household.33
When judgments were made about who was most susceptible to tuberculosis, something
was inevitably being said about the quality of those people. To classify one group as being more
susceptible to tuberculosis than another had varying meanings across the ages. In the eighteenth
and nineteenth centuries, it was considered twisted as it may seem given the devastating nature
of the disease a point of honor to be among those of the worlds nobility whose precious lives
were cut off in their prime by the Great White Plague.34 But it was only in the notion of joining
the ranks of the elite that one could take some small bit of solace in ones own unfortunate state
or that of a loved one. By the twentieth century, as the sterile medical outlook began to take hold,
tuberculosis lost any small bit of charm that it may have had. The reason for this change can be
difficult to deduce, but one possible explanation not yet examined in this essay could have had to
do with the drop in the diseases prevalence. When the disease was so common as to be
responsible for the deaths of every one in five individuals,35 it was more challenging to confine it
to one specific group of people. As a result, the descriptions used to characterize the typical
tuberculosis victim of the eighteenth and nineteenth century were much more vague. For
example, how exactly was a narrow chest defined? How light was light-skinned? When
tuberculosis death rates began to decline accounting for as little as four percent of all deaths by
the year 193936 it became easier to associate the disease with some distant, more precisely
distinguished other, that could be shuttered away from polite society. The move to viewing
tuberculosis as a disease of inferior people instead of one of the enlightened happened at the
same time as tuberculosis death rates fell. Was this a coincidence?
What cannot explain the decrease in tuberculosis rates is its shift from a disease that
affected everyone to one that targeted select groups of people. One can see from the AfricanAmerican example that this was not the case: The decline in the tuberculosis rates for the black
population was noted to be similar to the decline in the white population.37 Regardless of
whether tuberculosis truly was more frequent in some groups than in others in the past, this
notion does not exist any longer, at least not on the basis of a purely racial susceptibility to the
disease. According to the CDC, a weakened immune system is the primary risk factor for
contracting tuberculosis today. Numerous reasons for having one are listed HIV infection,
substance abuse, and diabetes among them but no mention is made of race, ethnicity, gender,
social status, or any other category of a similar sort.38 People are no longer waiting in suspense
for a hereditary consumption to strike. The shock value is gone, but two monsters still live:
tuberculosis which may eventually be eradicated and discrimination which was here long
before the segregating tendency of tuberculosis was an issue, and almost certainly will continue
on for a long time.

33

Hetherington and Eshleman, Nursing in Prevention and Control of Tuberculosis, ix-x.

Leroy, Pulmonary Tuberculosis, 11.
35
H.P. Ferrer, Screening for Health: Theory and Practice (London: Butterworths, 1968), 47.
36
Hetherington and Eshleman, Nursing in Prevention and Control of Tuberculosis, 7.
37
Ibid., 9-10.
38
Basic TB Facts, accessed November 18, 2013, http://www.cdc.gov/tb/topic/basics/risk.htm.
34

Miriam Goldstein

Fall 2013

Bibliography
John Armstrong, Facts, Observations and Practical Illustrations Relative to Puerperal Fever,
Scarlet Fever, Pulmonary Consumption, and Measles (Hartford: O.D. Cooke & Sons,
1823), 177-339.
Basic TB Facts, accessed November 18, 2013, http://www.cdc.gov/tb/topic/basics/risk.htm.
Elaine G. Breslaw, Lotions, Potions, Pills, and Magic: Health Care in Early America (New
York: New York University, 2012), ix-200.
William Mason Cornell, Consumption Forestalled and Prevented (Boston: French, 1846), iii120.
H.P. Ferrer, Screening for Health: Theory and Practice (London: Butterworths, 1968), xi-212.
H.W. Hetherington and Fannie Eshleman, Nursing in Prevention and Control of Tuberculosis
(New York: G.P. Putnams Sons, 1945), xix-332.
Louis Leroy, Pulmonary Tuberculosis (Nashville: Foster, Webb & Parkes, 1910), 1-94.
William A. MDowell, A Demonstration of the Curability of Pulmonary Consumption, in All Its
Stages: Comprising an Inquiry into the Nature, Causes, Symptoms, Treatment, and
Prevention of Tuberculosis Diseases in General (Louisville: Prentice and Weissinger,
1843), 1-259.
Thomas Reid, An Essay on the Nature and Cure of the Phthisis Pulmonalis, or, Consumption of
the Lungs (Philadelphia: Joseph Crukshank, 1785), iii-89.
Robert Koch and Tuberculosis, accessed November 17, 2013,
http://www.nobelprize.org/educational/medicine/tuberculosis/readmore.html.
Francis Bowes Sayre, An Inaugral Dissertation on the Causes Which Produce a Predisposition
to Phthisis Pulmonalis, and the Method of Obviating Them (Trenton: Isaac Collins,
1790), 7-24.
Tuberculosis Among Jews, The British Medical Journal, 1908, 1: 1000-1002.
John Harley Warner and Janet A. Tighe, Major Problems in the History of American Medicine
and Public Health (Boston: Wadsworth, 2001), 1-539.