Spitting Blood: The History of Tuberculosis by Helen Bynum (review)

Tuberculosis provides an almost irresistible subject for the historian of medicine. The disease’s long history is clearly intertwined with economics, politics, and culture; talented scientists have tackled its complex etiology, colorful and revealing institutional and clinical approaches have embodied (and sometimes established) the orientations and vogues of succeeding eras, and—an unhappy bonus for opponents of simplistic, positivist, and progressivist narratives—it has in recent decades itself returned from the dead (or, at least, from the presumed dead) to become again a much-publicized public health problem. As an undergraduate exclaimed in the introductory session of a recent course on the history of TB, “I just don’t understand how a disease that we know so much about, and have cures for, can still kill so many people.” Music to a historian’s ears.

There exists a rich body of scholarship on the history of TB, and Helen Bynum has expertly integrated it with her own research into the first readable and historically sophisticated survey of the history of that disease. In so doing, she also provides a fine entrée into the historical literature on TB (amplified by well-chosen suggestions for further reading) and an effective introduction to the history of medicine in general. She is a fine storyteller who writes in clear prose, and her grasp of the historical issues is firm and her approach nicely balanced and nuanced. At each juncture in the story, she invokes and discusses the relevant biology, scientific and clinical approaches, institutions, and social-cultural circumstances embedded in the human experience of TB—and incorporates important information and deft observations about more general trends in science, medicine, and society. Framed with a prologue and epilogue are well-conceived and executed chapters on the natural history of mycobacteria, ancient and early modern ideas about and experiences with phthisis and consumption, Morgani’s anatomical studies and the neo-Hippocratic views of the Enlightenment, the consumptive “fashionistas” of the Romantic era, bacteriology’s transformation of consumption into tuberculosis, cures and treatments of the late nineteenth and early twentieth centuries (tuberculin, pneumothorax, and sanitoria), tuberculosis as a “disease of civilization” and target of the New Public Health in the early twentieth century, the development and use of antibiotics, and the “return of tuberculosis” (a slogan toward which Bynum relates with appropriate skepticism) in the second half of the twentieth century. This organization, along with the volume’s readability and consistent, informed discussion of general themes, makes Spitting Blood ideal for use in survey courses on the history of medicine, as this reviewer can testify from experience.

As with any wide-ranging and necessarily selective work, there are places where one might quibble and obvious lacunae. For example, in this reviewer’s opinion, Bynum’s treatment of Robert Koch is too one-dimensional with no attention to the instructive evolution of his views from his early, confidently reductionist attitude in “Etiology of Tuberculosis” (1884) to his later reluctant acceptance of all the conceptual and practical difficulties associated with the problem of hidden carriers. Her illuminating and evocative discussions of individual patients focus almost exclusively upon elites, the middle class, and intellectuals and literati such as John Keats and George Orwell, and neglect the indigent and working-class patients whom, among others, Paul Farmer brings to life so well in his Infections and Inequalities.¹ Spitting Blood is also limited by its almost exclusive attention to tuberculosis in the West.

As history, Spitting Blood is qualitatively superior to the only other volume with which it might be compared by its scope, readability, and usefulness for courses—René and Jean Dubos’s wonderful The White Plague (1952, 1987, and 1996, with a very useful biographical preface by David Mechanic and historical introduction by Barbara Rosenkrantz).² The Dubos’s book (curiously unmentioned in Bynum’s text) is not only decades out of date, but also, of course, a powerful and in some ways prophetic...