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Medical Notes: Youth goes pale and spectre thin, then dies

COMPARED TO political, economic, social, cultural and even climatic history, all tirelessly mined by professional historians, little is known about the diseases of the past. Yet they affected the lives of millions in two different ways. The diseases themselves often changed historic events. But more pervasive, though even more difficult to document, were the widely perceived images of the illnesses, some close reflections of reality, others recognisable but transformed by popular imagination.

Of no affliction was this more true than of tuberculosis. Though undoubtedly ancient - evidence of it has been discovered in prehistoric remains and Egyptian mummies - as a great killer it burst on to the European scene with the industrial revolution. The England of Keats, Shelley, and the boy Dickens led the way, as she did in steam power and manufacturing industry, but soon the images of consumption were instantly recognisable everywhere.

The disease was often described as "white" - the white plague, the white death, the white killer - and this was more than a reference to the pallor associated with chronic blood loss.

To the European middle classes, who barely existed at the beginning of the tuberculous century and very nearly ruled the world by the end of it, tuberculosis posed an ethical conundrum. The illnesses and deaths of old people could be represented as natural phenomena, essential for the survival of the species. Illnesses in middle age too could sometimes be seen as just retributions for profligate or unwise living, the sins of the fathers being visited on the sons.

At the other extreme of life, a horrendous infant mortality was accepted as a law of nature. But tuberculosis, slowly killing the young in their prime - "where youth goes pale, and spectre thin, and dies" - crossing social barriers as well as national frontiers, needed a moral explanation. It became the image of sacrifice and atonement, Napoleon's son, the Eaglet, did not simply die in his gilded Austrian cage; he was consciously atoning for the bloodshed and suffering caused by his father.

But there was also a complementary image - or several complementary images. "Omnis phthisicus alax" - every tuberculous a lecher - was an oft-quoted saying; and there was truth in that too. The disease struck down and often confined to bed, house or sanatorium exile young people in their procreative as well as their creative flowering, longing to perform, yet able only to dream. Watteau's infinitely sad Departure for Cythera, the island where Venus taught her acolytes the art of love, is a pictorial elegy to lost sexual prowess. The artist died two years later, aged 36.

But above all, tuberculosis came to symbolise the longing for the unattainable - for a cure in the case of patients (like Katherine Mansfield, Franz Kafka or Robert Louis Stevenson) or simply for the kind of total happiness that is granted only rarely and then only for a few fleeting seconds to ordinary mortals.

The "message" of Chek-hov's last and greatest plays - all the pining and quiet desperation - sometimes puzzles literary critics: why could the three sisters, daughters of the valiant General Prozorov, not do the practical and the obvious and simply take the train to Moscow? After Ivanov tuberculosis is never mentioned by name in any of the texts, just as it was rarely mentioned in the correspondence of sanatorium patients; but pining was exactly what Chekhov himself and countless fellow tuberculous did in their remote Yaltas; and quiet desperation was their destiny.

But even in desperation there was always hope and, as they went on hoping to the end, and often in a breathless hurry, an astonishing number created some of the greatest works of art, music and literature.

Thomas Dormandy is the author of `The White Death: a history of tuberculosis', (Hambledon Press, pounds 19.99)