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Washington, Stuart D., Rakib U. Rayhan, Richard Garner, Destie Provenzano,
Kristina Zajur, Florencia Martinez Addiego, John W. VanMeter, and James N.
Baraniuk (2020) “Exercise Alters Brain Activation in Gulf War Illness and
Myalgic Encephalomyelitis/Chronic Fatigue Syndrome.” Brain
Communications 2, no. 2. https://doi.org/10.1093/braincomms/fcaa070.
Wood, Thomas Denison (1928) Teaching How to Get and Use Human
Energy. Bloomington, : Public School Publishing Company.
EBSCOhost: eBook Collection (EBSCOhost) printed on 12/28/2025 12:59:26 PM UTC via
HERZEN STATE PEDAGOGICAL UNIVERSITY OF RUSSIA. All use subject to
https://www.ebsco.com/terms-of-use.
Images of Tuberculosis: Seeing
and Understanding an Ancient,
Endemic Disease
Stephen A. Geller and Gideon Manning
Introduction
Prior to the nineteenth century, those who sought to picture disease
were not bound to the laboratory or hospital, or even to visual media,
as texts alone often created the medical picture of disease.
Developments in printing and the later separation of strictly
scientific/medical spaces from the public sphere—at isolated physical
locations where entry required training and expertise, and
concomitant privileged and distinctive knowledge—coincided with a
change in the generally accepted ideal conditions for visualizing
disease, prioritizing images taken from life and those utilizing the
microscope after the advent of compound achromatic lenses in the
1830s. The fundamental argument in favor of both was that they
improved accuracy in diagnoses and increased our causal
knowledge; in other words, such images and the procedures creating
them added “robustness” to the scientific and medical judgments of
the time. The nineteenth century’s emphasis on visualizing disease,
still integral to the scientific culture of contemporary medicine, takes
us beyond texts and the physical exam (though still essential) to the
development of anatomic pathology, histology, and histopathology
and, in time, to modern molecular pathology.
To explore some of the relevant transitions and image production in
the nineteenth century, in this chapter we consider images of the
endemic disease tuberculosis, concentrating on the changes taking
place inside the body and the etiology found with microscopy. We
examine images rendered approximately a century apart. One, a
representation of macroscopic findings produced by René-Théophile-
Hyacinthe Laennec (1781–1826), who introduced the stethoscope
and mediate auscultation to study the heart and lungs, and another, of
the causative micro-organisms themselves, discovered and drawn by
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Robert Koch (1843 –1910), who used innovative preparations and the
compound microscope to identify the cause of tuberculosis and
establish its communicability. We also consider, by way of contrast,
artists’ representations of the afflicted patients in their lived
experience of the disease in the work of Joseph Severn (1793 –
1879) and Edvard Munch (1863 –1944).
Tuberculosis was visualized both before and after the development
of laboratory science, and it continues to affect great numbers of
people well into the twenty-first century, especially in the developing
world. As a result, tuberculosis itself continues to be a valuable entry
point for understanding the changing practices and techniques for
picturing disease that animate this volume, allowing us to explore
significant episodes in the history of pathology through images.
We begin with a brief retelling of the history of tuberculosis,
including the earliest genetic and anthropological evidence including
bone involvement in fossils dated to 8000 . This section includes
discussion of contemporary pathology and what we know about
tuberculosis today. Part of our goal in emphasizing our current state
of knowledge is to indicate the extent to which specialized knowledge
—both scientific and medical—characterizes the pathologists’ studies
of disease.
In section two, we turn to the nineteenth century and utilize the
illustrations of Laennec and Koch. Here, we again specify the
technical knowledge and experience necessary to see what they saw,
but we also highlight the collaborative and cumulative nature of their
work and those on whom they relied as they responded to and
helped specify, through their publications, the ideal conditions for
visualizing disease. In Laennec’s case, we specifically describe how,
relying on postmortem study of diseased lungs and a sophisticated
didactic image representing progressive stages of the disease,
Laennec educated physicians to recognize changes occurring within
living patients but from the outside with the use of his invention, the
stethoscope. Laennec linked what he heard with his invention to what
he had seen postmortem, in effect grounding the art of auscultation in
the facts of the morphologioc alterations. In this way, he legitimized
the use of the “auditory eye” as a way of seeing inside the body when
direct and literal visual inspection of the patient’s organs was not
possible. Koch, by contrast, focused specifically on understanding the
contagious nature of this disease, isolating microorganisms from the
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body’s fluids and then, using his microscope and animal studies,
identifying the specific cause of tuberculosis. He relied on
sophisticated preparations (staining techniques) as well as techniques
for culturing the organism. Both scientists, Laennec and Koch, made
choices in how to visualize disease and both relied on more than a
static image to do so.
As we explain more fully in section three, the experienced
anatomic pathologist thinks and perceives dynamically, envisioning not
a singular moment captured in a slide or image but one linked to the
past and the future of the part, organ, and patient before them. This
differentiates pathologists from the public, even the well-educated
public. The pathologist’s image of tuberculosis may appear static to
the uneducated auditory or literal eye, but to the prepared pathologist
it represents a vivid saga that portrays a dynamic battle, including its
various beginnings, its many skirmishes, and its paths for
denouement.
The message of our contribution, emphasized throughout and
highlighted again in our conclusion, is that acoustic impressions,
originally conceived of by Laennec, when correlated with macroscopic
observations and subsequent microscopic images by Koch, have
been vital in expanding the understanding of tuberculosis and the
robustness of medical diagnosis. They have served to define what it
means to perceive disease. Put simply, these efforts to make clinical
judgment more reliable and medical interventions more effective led
to a multiplicity of independent and highly technical determinations of
the same result: that a patient was suffering from or infected with
tuberculosis.
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A Brief History of Tuberculosis
The history of tuberculosis is too well known to require anything more
than brief retelling here. Although the name first appears in 1839 in
the work of the German physician Johann Lukas Schönlein (1793 –
1864), the history of the disease is much older. The Hippocratic
corpus, originating in the fifth century , called tuberculosis
“phthisis,” one of several ancient terms for progressively wasting or
consumptive diseases (Nutton 2004, 28). Not necessarily identical
with tuberculosis, “consumption,” the pre-nineteenth-century English
word for tuberculosis, first appeared in the late fourteenth century,
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and “consumption cough” dates to 1661. The shift in terminology to
“tuberculosis” in the nineteenth century highlights a specific anatomic
feature of the disease, namely the tubercle, a small tissue mass so
named in the sixteenth century. Not to be outdone by later
physicians, however, the Hippocratics observed typical tubercular
lesions (“phymata”) in cattle, sheep, and pigs, although they did not
connect them to the same disease. They also believed tuberculosis to
be inheritable, which would be consistent with the appearance of the
disease within families who lived in close quarters with one another.
In later antiquity, Aristotle (384–322 ), who knew the
Hippocratic tradition well and showed extensive interest in medical
questions throughout his working life, characterized tuberculosis in
animals as contagious within herds, identifying the disease “branchos”
and “craurus.” He noted in History of Animals that both pigs and
cattle in herds are susceptible to “cranurus,” which can be confirmed
in cattle “when the carcase [sic] is opened the lungs are found to be
rotten.” Pigs also suffer from “swellings about the windpipe“ called
“branchos,” which we now know to be enlarged, infected pulmonary
hilar lymph nodes (vol. 1, bk. , sec. 21 and 23). By the first
century , the Roman author Aretaeus of Cappadocia, who was one
of the first physicians to attempt a systematic correlation between
disease and anatomic change, defined pthisis explicitly as a condition
typified by a cavity or abscess of the lung, with the patient
experiencing cough, expectoration, and bloody sputum (hemoptysis)
(bk. 1, ch. ; cited in Meinecke 1927, 387).
Many other Greek and Roman physicians wrote about
tuberculosis, but none more eloquently than Caelius Aurelianus of
Sicca, a fifth-century Roman physician and translator whose
description rivals that of any later clinician:
The patients suffer from a latent fever that begins toward
evening and vanishes . . . at the break of day. It is accompanied
by violent coughing, which expels thin purulent sputum. The
patient . . . breathes with difficulty. . . . The skin on the rest of
the body is ashen. . . . The eyes have a weary expression, the
patient is gaunt . . . but often displays astonished physical or
mental activity. In many cases wheezes are heard in the chest. .
. . The patients lose their appetite or suffer hunger pangs. They
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are often very thirsty (cited and translated in Herzog 1998, 5–
6).
In its fundamentals, this is precisely what we should expect a
contemporary clinician to report after taking a history and examining a
patient suffering from chronic tuberculosis: fever appearing worse in
the evening, a productive cough with clear or possibly bloody sputum,
difficulty breathing, gray pallor, weight loss, hyperactivity, audible
wheezing, shifts between hunger and little appetite, and significant
thirst.
We know today that tuberculosis is a highly contagious disease
caused by the bacterium Mycobacterium tuberculosis ().
Typically, the lungs and pulmonary hilar lymph nodes are affected but
the disease can also involve other parts of the body. In many cases
there are no symptoms (“latent tuberculosis”). A small percentage of
patients (approximately 10 percent) progress to active disease which,
if untreated, leads to death in as many as half the affected patients.
Typical complaints of active tuberculosis are chronic cough with the
production of bloodstained mucus, fever, high sweats, and weight
loss. The pronounced weight loss often seen is the historical basis for
the name “consumption.” Depending on the site involved, symptoms
can vary significantly. For example, bone pain is experienced when
tuberculosis involves the bone. Also, back pain and deformity are
associated with vertebral body tuberculosis, known as Pott disease
after the description by the so-called “best surgeon in England,”
Percival Pott (1714–1788). Vertebral involvement has been
observed in Egyptian mummies in whom the characteristic lesions
have been seen and, in modern times, demonstrated with
histochemical and immunohistochemical methods, as well as
molecular studies.
The original focus of tuberculosis organisms in the lung is met with
a transient and ineffective acute inflammatory (polymorphonuclear
()) reaction, similar to the body’s reaction to any infective agent.
When this reaction fails to destroy and isolate the organisms, the
area of infection enlarges as more effective chronic inflammatory
cells (lymphocytes, monocytes, and macrophages) replace that first
futile response, forming a distinct nodule (“tubercle”). The lesions
continue to grow, and may begin to show central necrosis, with the
influx of more inflammatory cells; it can then be seen with the naked
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eye on dissection or with imaging techniques, such as X-ray. The
inflammatory response leads to cell death, further necrosis, and
eventual cavitation, which can be many centimeters in diameter.
When the necrosis breaks into small bronchi, the organisms spread
throughout both lungs and also to the gastrointestinal system when
tubercular material is swallowed. Tubercles can destroy small vessels
in the lung with bleeding and hemoptysis. When larger vessels are
eroded, hemoptysis can be massive with severe bleeding and death
(“Rasmussen aneurysm”).
Fibroblasts (cells that elaborate collagen deposition and scarring
as attempts to wall off the process) infiltrate at the periphery. The
monocytes/macrophages merge as chronicity ensues to form
multinucleate giant (“Langhans”) cells arranged in a peripheral,
palisaded pattern surrounding the antigen-rich tuberculosis. This
fibrosing granuloma (an inflammatory nodule, not to be confused with
granulation tissue, capillary-
rich fibroblasts, typically seen in non-tubercular healing wounds) can
limit the spread of the infection although viable organisms can be
identified and cultured from granulomas in the laboratory decades
after both the original infection and recognizable symptoms. When the
necrosis is large enough to see macroscopically it resembles a soft,
white cheese and has been termed “caseous” (cheese-like, meaning
something resembling pot cheese or cottage cheese). The classic
depiction of tuberculosis, combining macro- and microscopic features,
is that of caseating granuloma(s) with chronic inflammatory cells and
characteristic multinucleate (Langhans) giant cells.
2
Visualizing Tuberculosis
In 2025, physicians know a great deal about tuberculosis, its signs
and symptoms, and how to prevent its spread. How they think about
and especially how they visualize the disease, its cause, and
pathogenesis, can be traced to two physicians and the reception of
their work in the nineteenth century: Laennec and Koch. Laennec saw
the effects of the disease’s lesions on the lungs postmortem and then
developed techniques for seeing the disease inside the live patient
using what we call here the “auditory eye.” For his part, Koch saw
and demonstrated the causative bacillus of the disease, building on
the clinical advances that came before him as well as his own and
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others’ laboratory work with anthrax utilizing the microscope to
connect bacteria and disease. We work in the reverse chronological
order in this section, and so begin with the more familiar laboratory
medicine of today, by starting with Koch and ending with Laennec. In
this way, we move from the micro level upward to the gross anatomy
and then the clinical encounter. By comparing the two figures, we will
see how each depended on collaborators, both scientific and artistic,
but in different ways, and how the drive for reaffirming and self-
correcting methods in nineteenth-century scientific medicine altered
the consensus of how best to see and visualize disease. In other
words, the struggle for reliability and effectiveness led to independent
and ever more robust derivations of the same result: an identification,
through a combination of observation, inference, and experimental
manipulation of the presence and progression of tuberculosis in a
patient or animal subject.
Koch was one of many to pioneer techniques of photography
through the microscope, and photography was in the late nineteenth
century taking its cultural place in science and medicine. But,
interestingly, in Koch’s demonstration of the microscopic appearance
of the bacillus utilizing histochemical methods, he relied on a color
drawing rather than photographs. Koch drew what he saw
under the microscope with his own hand because color
photomicrography had not yet been developed and the testimony of
his own eyes, and hand, carried epistemic weight with his colleagues.
Koch had earned considerable fame for his work studying anthrax in
animals prior to studying tuberculosis. When he turned his attention
to the latter, he used similar techniques to those he successfully used
when studying anthrax, although tuberculosis presented specific
challenges.
FIG . 1
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FIG. 1 Robert Koch’s hand-drawn and colored illustration of the blue rod-like
structure of Mycobacterium tuberculosis seen through the compound microscope.
(Koch 1912, Table XXVI, fig. 34.) Wellcome Collection. https://wellcomecollection.or
g/works/g6yw6n8t
One does not need to know a great deal about optics to look
through a microscope but one must remember that preparation is
essential to see anything at all with the device. To prepare his
samples, Koch used a methylene blue stain, developed by Paul
Ehrlich (1854–1915), with Bismarck brown counter-stain. He began
with a sputum sample from a patient independently diagnosed with
tuberculosis. Koch then employed solid nutrients including potato
slices to grow pure colonies of Mycobacterium tuberculosis (the blue
rods in figure 1). Animal testing followed when he inoculated that
material into susceptible animal subjects to reproduce the disease. In
this way, Koch identified the cause of tuberculosis.
Mycobacterium tuberculosis is a small, aerobic (oxygen-
dependent), nonmotile bacillus whose outer surface has a high lipid
content, contributing to many of its unique characteristics. These led
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to Koch’s early challenges in its isolation using existing staining
techniques and the microscope; cells are largely transparent and
require careful preparation to be seen. The lipid bilayer with a high
mycolic acid content does not stain well with the various staining
techniques, including the Gram stain, developed in 1884 by Danish
bacteriologist Hans Christian Gram (1853 –1938), still widely used to
identify most bacteria under the microscope. Koch responded to this
challenge by trying many stains before adopting the methylene blue
stain of Ehrlich.
Koch first presented the results of his work on tuberculosis in
March 1882 at a meeting of the German Physiological Society in
Berlin. Speaking to an audience of experts, including many trained in
laboratory science, Koch walked them through his preparations and
what the microscope revealed:
The bacteria visualized by this technique [Verfahren sichtbar
gemachten] show many distinct characteristics. They are rod-
shaped and belong therefore to the group of bacilli. They are
very thin and are only one-fourth to one-half as long as the
diameter of a red blood cell, but can occasionally reach a length
as long as the diameter of a red cell. They possess a form and
size which is surprisingly like that of the leprosy bacillus. (Koch
1882, 222; trans. Brock 1999, 110)
Others had looked for the cause of tuberculosis, but none had seen
what Koch saw. In his 1882 presentation, he had an explanation for
why his results had been missed by previous scientists and
physicians. For one, “the bacilli are extremely small structures.” For
another, they appear “in such small numbers, that they would elude
the most attentive observer without the use of a special staining
reaction.” Thus, in his own telling, it was Koch’s preparations that
brought the bacilli into view. But even with his preparations, when the
bacilli “are present in large numbers, they are generally mixed with
finely granular detritus in such a way that they are completely hidden,
so that even here their discovery would be extremely difficult” (Koch
1882, 431; trans. Brock 1999, 111). Indeed, before the development
of more recent visualization techniques, including immunostains,
pathologists were admonished to study slides for at least thirty
minutes or more before deciding the organisms were not there.
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