Spitting Blood begins with an account of George Orwell's life with and death from tuberculosis, illustrating the course of the disease just as effective antibiotic treatment was becoming available (he proved allergic to streptomycin). While it touches on many of the individual stories of both victims and scientists, however, it doesn't dramatise them: the focus remains on the medical and social history, situating tuberculosis in its historical and cultural contexts. (There is some emphasis on Britain and the United States, but decent global coverage.)

Nine fairly long chapters proceed chronologically, but it is short thematic sections within those that are the basic unit. Bynum begins with the biological history of Mycobacterium tuberculosis, the archaeological evidence for prehistoric tuberculosis, and the classical world's understanding of tuberculosis, or its most common symptoms, as phthisis. Medieval ideas about consumption drew on classical sources, but had a special place for the scrofulous, those with glandular tuberculosis and swollen neck glands; consumption was also linked to leprosy and plague.

The early modern period saw the beginnings of scientific anatomy and a focus on tubercles, with work by Morgagni, Baillie, and then Laennec's unification of a myriad of symptoms as one disease. Treatments, however, remained variegated, with the fancier options including sea voyages, spas, and gas inhalation. And consumption was fashionable in some circles, as is illustrated by the lives of Keats, the Bronte sisters, and Violetta from Verdi's La Traviata.

Tuberculosis played a key role in the development of microbiology, though Koch's explanation of it as an infectious bacterial disease met opposition. Early public health initiatives were started by Philips in Edinburgh and Biggs in New York: these were the forerunners of huge systems of sanatoria and other communities with rules governing everyday life and activities. Treatments and preventative measures included Koch's tuberculin, lung collapse therapy, the pasteurisation of milk, and BCG vaccination; tuberculosis also had connections with racial ideologies and eugenics.

Effective treatment arrived in the middle of the 20th century, with the development of streptomycin and x-ray diagnosis; those were followed by mass screening campaigns and the development of additional antibiotics and standard chemotherapy regimes. By the mid-1970s the world had largely lost interest in tuberculosis, but it has made a comeback since, mostly in connection with migrants and refugees, the new underclass, and HIV and AIDS. The DOTS ("directly observed therapy, short-course") treatment protocol became standard in the 1990s but has its limitations; dealing with tuberculosis remains "a job half done".

Bynum is informative and accurate without ever being academic. She provides references, but also twenty pages of accessible further reading notes, which describe some of the primary sources as well as other works about and connected to tuberculosis. Anyone after anecdote-driven purple prose should look elsewhere, but for those curious about the history of disease Spitting Blood is an excellent read.

August 2013

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