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(TB)—over the centuries, the disease caused by Mycobacterium tuberculosis has gone by many names. Evidence of human TB infection dates back almost . Even after all this time, the disease remains from a single infectious agent and is the prevailing . Its eradication is continually becoming more difficult due to the frequent emergence of . However, despite this long and deadly history, there was a time when it was considered a fashionable affliction. 

During the of the late 18th and early 19th centuries, the characteristic consumptive appearance of TB victims was the predominant European beauty standard. Suffering from the disease’s effects was seen not only as a beautiful and dramatic way to die, but also an aspirational way to live. This idea was no doubt reinforced by the fact that many influential figures of the time were victims of the disease, including the poets and , and the composer . once said, “I should like, I think, to die of consumption… because then the women would all say, ‘see that poor Byron—how interesting he looks in dying!’” 

This obsession with a tragic and beautiful death worked its way into fashion, literature, theater and visual art. Its influence was so profound that even now, audiences know that when they meet a character with a cough in the first act, that character will likely be dead by the third act. Modern examples of this trope cross genres and diseases and include films like Moulin Rouge!, Bohemian Rhapsody and Tombstone. These movies romanticize the beauty or heroism of suffering from a fatal disease for art or an ideal. 

What Does a TB Victim Look Like?  

By the mid-19th century, TB had become an epidemic in North America and Europe. Its prevalence likely increased the popularity of the tuberculosis aesthetic from the 1780s to the 1850s. As numerous artistic figures contracted TB, it shaped public perception of the disease. Famously, Keats, who had trained in medicine, declared his own death sentence after seeing his blood-stained handkerchief following a coughing fit: “I cannot be deceived in that colour; that drop of blood is my death-warrant; I must die.” 

A popular myth arose that tuberculosis was mysteriously and preferentially "drawn to" Romanticists—an acquired, Romantic affliction that conferred enhanced enlightenment and beauty. Romanticists and belief as consistent with what ancient Greek physicians had referred to as a euphoria intermingled with depression that resulted in greater creativity. It was thought that as the body was consumed, the mind engaged in outbursts of inspiration in a struggle against impending mortality. Romanticists, such as Keats, became powerful symbols of the disease. It was believed that they possessed heightened sensibility, and that their work was elevated because of consumption’s effect on the mind. 

In reality, the slow growth rate of  bacteria usually causes a lengthy deterioration for its victims. This slow descent in a world before antibiotics caused specific changes in physical appearance. Frequent low-grade fever led to, rosy cheeks and red lips. Pale skin and weight loss resulting from lack of appetite and anemia further helped women conform to the notoriously small-waisted fashions of the day. Various artwork illustrated these direct results of  

One of the most famous paintings from the time, , depicts the character from Hamlet in a beautiful, natural setting just before drowning. She is pale and fragile with bright red lips and posed like a saint in a state of ecstasy. She possesses all the ethereal beauty and tragedy of the idealized consumptive woman.

Other popular depictions of women showed confined to a bed or draped across a chaise longue. Attributes that were already considered to be beautiful in women were enhanced by their suffering. As she watched her sister Anne dying from the disease, author, “Consumption, I am aware, is a flattering malady.” 

In Keats opens the poem by asking, “O what can ail thee, knight-at-arms,/ Alone and palely loitering?” and answers his own question in the third stanza, “I see a lily on thy brow,/ With anguish moist and fever-dew,/ And on thy cheeks a fading rose/ Fast withereth too.” The pale brow, feverish sweat and brightness of the cheeks in contrast to the skin’s pallor, again, refer to Romantic ideals of fleeting consumptive beauty. The poem reflects Keats’ dual afflictions: his consuming love for Fanny Brawne and the consumption that overwhelms his physical being. The knight, like the poet, strives for love and beauty though he knows his life is fading. 

In fact, without contracting TB, it was very difficult for women to achieve the consumptive chic aesthetic. Women’s dresses in the Romantic period required tightly laced and pointed corsets to create a narrow waist and a delicate, almost fragile silhouette. The extreme nature of fashion required strict dieting and often. Non-consumptive women used makeup to create a pale complexion and enhance specific features, such as rouge on their cheeks and lips, to create a "sickly" look. These products often contained like arsenic, ammonia, belladonna, mercury and opium. In this way, pulmonary tuberculosis became more associated with attractiveness than the grim realities of disease progression. These physical features, accompanied with shortness of breath caused by damaged lungs, contributed to the idea of women as fragile beings and reinforced strict gender roles. Theatrical depictions of women further cemented this idea of the beautiful, doomed heroine. 

Spes Phthisica—A Dramatic Way to Go 

Portrayals of this archetype appear in Alexander Dumas's stage play , and operas like Giuseppe Verdi’s and Giacomo Puccini’s . These stage productions feature women who exist outside of their prescribed domestic role in society and pay the ultimate price. They are redeemed through the strength of their love, although they are unable to change their fates. 

The creates an air of mystery and interest surrounding the consumptive character. If death is inevitable, what does the character have to lose? Without a real future, they are free to express themselves and truly feel. How long will they continue to linger and decline? Will a sudden emotional outburst like Violetta’s in La Traviata lead to immediate death? This existence on a knifepoint gives characters an extra level of interest or allure. 

The tragedies of Camille, Mimi and Violetta (heroines of the play and operas listed above) come from the lives they will not live. Keats’ poem “Ode on a Grecian Urn” exemplifies this. “Heard melodies are sweet, but those unheard are sweeter.” Their stories are beautifully tragic, but we will never know what kind of life they could have lived, had they survived. The dream of a perfect, natural existence for these women can never be realized and will always be more beautiful than their actual stories. This line exemplifies the Romantic and carries into characteristic themes, including the goodness of people, opposition to urban life and the simplicities of childhood and nature. 

Written Depictions 

The Romantic movement seems to have arisen as a counter to the changes society was undergoing due to the during this period. For many authors, consumption as a metaphor was an effective way to comment on the horrors of modern urban life, particularly for those living in poverty. In industrialized areas, tuberculosis became the leading cause of death among urban working-class people, due to, undernutrition and abysmal sanitation—all direct risk factors for tuberculosis transmission.  

Charles Dickens’ beloved character Tiny Tim from may have been a . Though never explicitly stated by the author, his symptoms do match Pott’s disease, or other organs. Spinal tuberculosis symptoms include , difficulty walking, arm and leg weakness and fever. Tiny Tim’s living situation was common in London at the time. His family lived in a small, overcrowded dwelling; their poverty meant they likely had poor nutrition and sanitation, all of which would have exacerbated his condition. As a metaphor for the innocence, purity and the physical suffering of the working class, Tiny Tim is shown to the reader as being slowly killed by the unnatural and uncaring environment of urban life.  

But consumption was by no means an exclusive illness of the poor. Its easy method of transmission meant it crossed class boundaries and affected people at all levels of society. By contrast, the characters in the novel live in more rural and affluent settings. Jane’s first ever friend at boarding school, Helen Burns, dies of consumption shortly after Jane’s arrival. Helen never loses her purity and stoicism, even in the face of cruelty from the teachers. She succumbs to her illness after teaching Jane mercy and forbearance. 

Brontë’s poem includes references to the consumptive look and symptoms in the 12th stanza: “Now I can tell by thine altered cheek/ And by thine eyes’ full gaze,/ And by the words thou scarce dost speak,/ How wildly fancy plays.” Brontë wrote of the wide, full eyes that were fashionably attributed to tuberculosis and the fanciful speech that was thought to be related to artistic genius, both hallmarks of the era. In the final stanza, the author exclaims the paradoxical nature of fleeting life and the stories that remain, writing, “Nature's deep being, thine shall hold,/ Her spirit all thy spirit fold,/ Her breath absorb thy sighs./ Mortal! though soon life's tale is told;/ Who once lives, never dies!" The poem’s final 5 lines are echoed in the author’s words, written after the passing of her sisters Emily and Anne Brontë. 

Anne and Emily Brontë, along with their brother Branwell, are thought to have died from tuberculosis. In Charlotte Brontë revealed her sisters’ author pseudonyms, , while commenting on their declining health, which she attributed to consumption. On their failing strength in the final days, Charlotte wrote, “Neither Ellis nor Acton allowed herself for one moment to sink under want of encouragement; energy nerved the one, and endurance upheld the other. ... But a great change approached; affliction came in that shape which to anticipate is dread; to look back on, grief.” She noted that Emily’s symptoms worsened first, until “we had nothing of Emily but her mortal remains as consumption left them.” 

In his poem “On seeing a Lock of Milton’s Hair” (1818), Keats wrote in stanza 4, “For many years my offerings must be hush’d;/ When I do speak, I’ll think upon this hour,/ Because I feel my forehead hot and flushed,/ Even at the simplest vassal of my power,/ A lock of thy bright hair,—”. In these lines, Keats layers references of his own experiences with tuberculosis with the belief that his literary predecessor, , succumbed to the disease. The poem also references the fever associated with tuberculosis.  

Keats frequently mentioned in his letters that he was restrained from using his full voice, due to the disease. In a , Keats wrote, “you must not mind about my speaking in a low tone, for I am ordered to do so though I can speak out,” indicating his adherence to advice regarding his condition and the behavior that he alluded to in his poem.   

Modern Understanding 

As scientific understanding grew and microbiological research from John Snow, Robert Koch and Louis Pasteur demonstrated that , the reality of consumption could not be ignored—it is and always was a contagious disease, not an acquired affliction that preferred the Romanticists—and the  aesthetic fell out of favor.

Still, the cultural impact of the consumptive look lives on. In modern television and cinema, the  is a reliable indication of a character’s inevitable end. Often, the character’s death is framed and foreshadowed sympathetically, evoking true pathos to remind the audience what Keats, Byron and Brontë memorialized in their words. From Greta Garbo’s portrayal of Marguerite Gautier in  (1936) to Nicole Kidman as Satine in Baz Luhrmann’s movie-musical  (2001), the painful cough and bloody sputum associated with active tuberculosis have been ingrained in the cultural consciousness as symbols of fragility, mortality and sympathy.

Worldwide, TB remains the leading cause of death by infectious disease. This is due to the fact that many of the same risk factors from the Romantic period persist to this day: poverty, crowded and poorly ventilated  and poor nutrition. Unfortunately, the the overuse of antibiotics in the modern world has added to the difficulty of defeating tuberculosis. Inappropriate antibiotic use leads to the development of , as well as , making infectious disease prevention and treatment increasingly difficult.

TB still has a lengthy disease progression; modern TB treatment regimens last for a median of 6 months, or in the case of MDR, 18-24 months. During this time, patients can still spread the disease. Careful treatment adherence and monitoring is not always possible in resource constrained areas, and if the treatment course is not completed, disease may reoccur. Fortunately,  are being developed to fight emerging resistance.  Perhaps one day, thanks to , we may destroy the colossus that is tuberculosis and little will remain of the once horrible threat.

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