Wednesday book: A killer that never went away

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A DOCTOR'S first duty is to do more good than harm. How rarely that duty has been honoured in the last 200 years! The march of science is slow and stumbling, and the central lesson of this book is that progress is always halting, with false starts and wrong turnings. Scepticism is the only proper response to medical claims and counter-claims, however distinguished their proponents.

Tuberculosis has defied medical science for 2,000 years, and still defies it now. Over the past two centuries, since John Keats coughed, turned his pillow crimson and died in 1821, its incidence has risen and fallen without apparent regard to the laws of science. So have the ways of treating it.

We seldom hear the term "invalid" these days, although more than half the population over 65 describe themselves as having a chronic ailment, according to last month's Social Trends. The word conjures up images of patients swathed in bedclothes, sipping weak broth and waiting for an appointment with their maker. Yet little more than 50 years ago it was not uncommon for tuberculosis sufferers to spend months or years in one of the many sanatoria that sprang up around the turn of the century. Now it is rare for any patient to spend more than a few days in hospital - and tuberculosis victims are not admitted at all. They are treated with drugs as outpatients.

If times change, medical hubris does not. Tuberculosis had always been thought a disease of polluted towns, where damp houses and overcrowding facilitated the spread of infection. But in Britain, its highest incidence through the 19th and much of the 20th century was in the mountains of rural Wales, and Norway was one of the most heavily infected countries in Europe.

The highest mortality in the world was among the Bantu workers in Johannesburg. There was a complex interplay between social, economic and immunological factors, but this was unrecognised and even less understood. About 150 years after Keats's death, Sir George Pickering, professor of medicine at Oxford, observed that the history of medicine was a monument to human folly.

The grimmest warning in Thomas Dormandy's book comes in the final chapter. After decades in which doctors had advised all manner of strange remedies, many of them lethal (including bloodletting, gold injections and enforced rest), the breakthrough came with the discovery in the Forties of streptomycin and isoniazid, soon to be followed by other drugs. It looked at last as though the disease was beaten. But the optimism has proved to be short- lived. Tuberculosis, always an opportunistic infection, has reappeared with a vengeance.

The reasons are the rise of Aids and the growth of drug-resistant strains. The emergence of these strains caused near panic in medical circles in New York when first observed in the late Eighties, for it left doctors with almost as few options as they had had at the time of Keats.

Nor should anyone take comfort from the idea that the disease is confined to Aids. Tuberculosis linked to Aids has never accounted for more than 20 per cent of cases. Nor is it a disease confined to the poor. I know one middle-class family of four, three of whom contracted the disease in quick succession. One, an actress waiting for a Concorde flight to New York, vomited blood all over the white carpet of British Airways' VIP lounge.

As Dormandy observes, every illness has a personality that affects more than its victims. Tuberculosis infected the entire culture. This was not only because it killed so many of those who created it (the list of victims reads like a roll-call of genius: Chopin, three of the Brontes, Kafka, Beardsley, Modigliani, Mansfield, Stevenson, Lawrence, Chekhov, Orwell) but because it also imprinted itself on the creations of the non-tuberculous majority. Thus its history is more than a history of medicine. It was not only a killer (there were plenty of those); it transformed lives as well.

This is a scholarly and thorough book, as comprehensive a history as you are likely to find. Dormandy is a consultant pathologist with a long interest in the disease and he writes in a terse, sceptical and open-minded style, with occasional coruscating asides on the foibles of his medical forebears. What are missing are some explanations. I could find no account of what tuberculosis is. I still have no idea what a diathesis is, despite having read a chapter under that heading. Similarly, a discussion of pneumothorax does not explain what it is. For a non-medical readership, these are strange omissions which might have been avoided with more careful attention from an editor.

The story remains a remarkable one, because it is not yet over. Dormandy says that what has characterised the tuberculous imagination is a capacity for hope and a determination to fight in this life. There is much fighting still to be done if Homo sapiens is to outlive Mycobacterium tuberculosis. But don't bet on it.