The Contagious Question of Tuberculosis

This paper explores how tuberculosis (phthisis/ phthoe) was understood and characterized in Greco-Roman antiquity as a disease transmissible between people. Although human-to-human transmission of tuberculosis was observed by non-medical authors, among the medical authors only Galen acknowledges its transmissibility. This paper explores the reasons for this disconnect between secular observation and medical theorizing about contagion, with tuberculosis as the specific case-study.

I address this question by analysing four key passages that indicate the known danger of proximity to consumptives and situating them within the broader discussion of disease transmissibility, building on previous investigations into ancient understandings of contagion (Nutton 1983, 2000a, 2000b; Grmek 1984; Hankinson 1995; Longrigg 2000; Jouanna 2012). In Isocrates, laymen give warnings against caring for a consumptive since most carers consequently die from the disease (Isocrates, Aegineticus 29). Ps.Aristotle asks the question why only some diseases, like consumption, are contagious and posits that the patient’s diseased breath being inhaled by others is to blame (Ps.Aristotle, Problemata 887a23-35). Galen says it is obvious that proximity to consumptives is dangerous, as is proximity to all those whose exhalations are putrid and noisome (Galen, De Differentiis Febrium 7.279K). Plutarch questions why the custom where the children of a parent who died of consumption place their feet in water until the deceased’s corpse is burned is thought to prevent consumption passing to the child (Plutarch, De Sera 558d-e). Considering tuberculosis’ sporadic patterns of manifestation, this paper explores the superstitious and rational underpinnings of these observations of transmissibility and the reluctance of medical authors to readily accept and explain what the populous observed.

Phthisis was a common, incurable, and fatal disease; immediately recognizable because of the sufferer’s symptoms of paleness, coughing, spitting blood, and wasting away (e.g., Hippocrates, Prorrhetic 2.2). Often considered divine retribution for religious transgression and associated with moral impropriety and vices in philosophical texts (set as the bodily counterpart to a thoroughly corrupted and incurable soul e.g., Aristotle, Nicomachean Ethics 1150b), consumption carried stigma in the general population. These connotations combined with entrenched concepts of an individual’s miasma as a polluting force on the collective (Parker 1983) led the Hippocratic authors who eschewed supernatural explanations of medical phenomena, to deny the empirical observation of human-to-human transmission of phthisis. For them, contagion was a concept so deeply associated with magico-religious explanations of the world that they instead focused on framing their understanding within theories of individualized nosology, heredity, environmental influences on an individual’s humoral constitutions and their susceptibility to the disease. They relied on explanation through perceivable forces, e.g., smell, since noxious effluvia, sputa and other excreta were the diagnostic hallmarks of consumption. The doctor’s priority was pragmatic: to treat the patient. Knowledge of transmissibility (e.g., in plague times) resulted in ethically unacceptable consequences such as abandoning care for the sick altogether (Thucydides, Hist. 2.51). By undertaking a case study of one of the few diseases that was occasionally considered transmissible, we gain greater insight into the theoretical, practical, and ethical underpinnings of contagion understanding in antiquity.