Tuberculosis has been called the social disease. It has lived with mankind for thousands of years, and our view of the disease has changed with time and social context. On World Tuberculosis Day (24 March), here’s an example of how attitudes towards a key symptom of the disease – coughing up sputum – changed during the course of the 19th century.
In the 18th century spitting in public was a common and socially acceptable habit in Europe. Far from being frowned upon, spitting was even encouraged in etiquette manuals. Often associated with chewing tobacco, spittoons were used as containers for spit and could be found both inside and outside of public places, such as public houses.
By the 19th century manners had changed, and there was “a certain class-based repugnance” at the habit of public spitting. The change in attitude towards spitting was reinforced by a greater awareness of the transmission of contagious diseases. But a sense of revulsion at the habit as much as medical concern about spitting informed public health campaigns of day.
The emblematic image of the tuberculosis sufferer is the Romantic consumptive coughing into a handkerchief. It was known that pulmonary tuberculosis (also known as phthisis and consumption) significantly increased expectoration. In the later stages sufferers often spat blood.
Tuberculosis was increasingly acknowledged to be a contagious disease, confirmed in 1882 when Koch discovered the tubercle bacillus. Spitting was thought to spread tuberculosis via dried sputum particles dispersed through dry sweeping of floors, or by spitting onto handkerchiefs and letting them dry on furnishings and bed linen.
Public health became vital a tool in the control of tuberculosis and spitting in public became the subject of public health education in many countries.
In France, in 1898, the Academy of Medicine declared a War on Tuberculosis. The thrust of their attack was contagious spittle. In his report to the committee, the physician Joseph Grancher declared: “We know…that the tuberculeux who spits or excretes his bacilli is dangerous and we must be protected from him”.
The working class were most commonly blamed for careless public spitting. The negligent worker who spat in public was a threat to his family and to society at large because he might cough up spit and infect innocent bystanders.
The French strategy was to discourage spitting and encourage the use of spitoons so that spittle could be disinfected. In 1900 population density (in overcrowded housing) and alcoholism were added to the social causes of tuberculosis along with spitting.
A similar approach could be found in Britain. In his 1903 report, Sidney Davies, the Medical Officer of Health for Woolwich reported on the problem of public houses as a source of tuberculosis infection. Because public bars were frequented by working men “in all stages of consumption and that spitting on the floor is a general practice in these places, it is to be expected that they should be a fruitful source of infection.”
He carried out tests on samples of bar sweepings from six public houses and found tubercle bacillus in two of them. Here is his full account in the MOH report:
Some felt that the focus on spitting was a displaced concern about wider social issues, nevertheless in many countries including France, Russia and Britain, vigorous campaigns against spitting were a universal feature of public health measures against tuberculosis.
Author: Lalita Kaplish is a web editor at the Wellcome Library