Hester Jane Ervin Howard with Robert’s dog Patch outside the Howard home in Cross Plains, Texas, ca. 1924.
1. The Shadow of Tuberculosis
Hester Jane Ervin Howard’s death certificate states she died of tuberculosis on June 12, 1936. A puzzling diagnosis and difficult to understand when TB is never referred to in any of the letters written by either her son, Robert E. Howard or her husband, Dr. Isaac M. Howard.
To understand why it is not mentioned by REH and his father, it’s essential to know about tuberculosis, its history, causes, symptoms, pain and suffering and especially the stigma and fear that surrounded it.
A Short History of TB
The girl sits propped up on pillows. Her face has become almost transparent. She turns towards the window. Cold winter sunlight streams in. Faint dashes hint rather than depict her eyes; yet the wistful gaze is miraculously caught. Her orange hair glows against the white linen of the bedclothes. A green curtain billows into the room. Next to her the mother’s head is sunk on her chest, hardly more than a shadow. It is the image of inexpressible grief…This is the picture of Sophie Munch, aged fourteen…a few months before her death from tuberculosis. [Two years later Munch’s mother also succumbed to the same disease.] Painted by her brother Edvard, it is one of the graven images of what was for millions a personal experience. (Dormandy Introduction)
A Sick Child by Edvard Munch, who also painted The Scream
A thousand million people died of tuberculosis in the nineteenth and twentieth centuries. (Ryan 3) Nor was it a new disease. Paleontological records tell us symptoms of tuberculosis appeared in a Neolithic grave near Heidelberg dated at 5,000 BC during the Stone Age, as well as in the spines of Egyptian mummies. (4) The disease was already established in mainland Europe by 2,500-1,500 BC and it is likely it came to England about a thousand years later. (6) TB even predates Columbus in the new world where it has shown up in the skeletons of Native Americans and Peruvian mummies as well as in the bones found in countries around the world, including Japan. (8) In fact, “Dr. John Stanford, who has spent his life studying TB, believes that the tuberculosis germ is very ancient, and may well have fought for its survival in the primeval mud of the earth at the very beginnings of time.” (Ryan 6)
Tuberculosis was called by many names: phthisis, consumption, wasting disease, weakness of the lungs, graveyard cough. (Dormandy 22) During the late nineteenth century there was a growing fear the disease might destroy European civilization. (Ryan 8)
It is a remarkably enduring disease. Once it arrives in a community, it stays. (6) By mid-seventeenth century, one in five deaths was due to consumption, which is an older and rather more descriptive name for the pulmonary form of TB. As a result, it became known as the “White Plague of Europe.” (7) Although the death rate had been declining since the 1840’s in the year 1900, the world’s death rate from tuberculosis was about seven million people a year with fifty million more openly infected and at least half the world population had come into contact with it. (Ryan 8)
There were popular misconceptions about tuberculosis, even as late as the 1970s and 80s. According to L. Sprague de Camp, a Robert E. Howard biographer and author of Dark Valley Destiny,
Tuberculosis is a strange disease. Relatively rare today, in 1900 it was second only to pneumonia as a major cause of death. Whenever people move about a lot, whenever there is crowding, unhygienic living conditions, poverty, or privation, tuberculosis becomes epidemic. (de Camp 32)
De Camp’s statement that TB was second to pneumonia as a cause of death is incorrect. In the early 1900s, it was the primary cause in the USA for many years. (CDC “Leading Causes of Death”) He was also wrong that it was an epidemic.
Unlike most epidemic diseases, TB did not sweep through a city or region and then disappear for several years. TB was endemic – it was a debilitating constitutional illness to which people succumbed slowly over a period of years, infecting and being re-infected, leaving the afflicted compelled to stop work, enter hospitals or sanitariums, and lie and dissemble for self protection. (Ott 6)
Above is a depiction of TB statistics in Kentucky during WWII. Below are two examples of the Christmas Seals campaign for fighting TB. Both of these were probably familiar to the Howards in Cross Plains.
1924 Christmas Seals Campaign
Christmas Seals Campaign, ca. 1935
Dr. Frank Ryan in The Forgotten Plague: How the Battle Against Tuberculosis was Won and Lost, explains how the body reacts to TB and how some survived while others did not.
We are infected by the germ that causes tuberculosis in two ways, either by inhaling it in the air we breathe, or by swallowing it food or drink. Inhalation is the commonest way in which it gets into our bodies, taking in bacteria which are suspended in dried dust or in tiny droplets. If a tiny colony on a culture plate contains in excess of a billion tuberculosis germs, consider the numbers of germs flung into the air by the single cough of an infected patient. Unlike AIDS, which is spread only by sexual penetration or by intravenous injection of blood products, tuberculosis is contracted simply by the act of breathing. Everybody is therefore susceptible. (Ryan 17-18)
But it is the pulmonary form of the disease which is by far the commonest and it was in this form that tuberculosis blighted the lives of billions of people. What happens is basically simple if dreadful. The bacteria inhaled in water droplets settle in the periphery of the lung and grow very slowly until they form a small local collection, like a cheesy boil. From this boil, the continuing infection spills over into nearby small airways and forms more of these tiny boils. It was the appearance of these small cheesy collections (like little tubers) which, in the early nineteenth century gave rise to the modern name, the disease in which you find tubercles in the lung or tuberculosis. This replaced the much older and more descriptive name, consumption…From this primary infection in the lungs, several things may happen. (Ryan 19)
In many, the first infection is fought off by the body. The white cells mop up the bacteria and the abscess is walled off from the rest of the lung by a fibrous shell. But our white cells have difficulty disposing of these ingested bacteria. That waxy shell can be as impervious to the digesting chemicals of our white cells as it is to acid, and tuberculosis has the horrifying ability to eat our white cells themselves from the inside and to grow and multiply while actually within the cells. In order to contain the disease, our body decides to accept stalemate and just wall it off. If we succeed, we lull ourselves into a false sense of security: we tell ourselves that we are cured. But tuberculosis remains alive within the fibrous shell and can burst out into life-threatening virulence at any time in the infected person’s subsequent life. (Ryan 19-20)
Where tuberculosis is common, most of the population will encounter germs when they are children. Yet here we discover another of its mysteries: the majority wall it off when it is still just a spot on the lungs and they never know they were infected. But if the body fails to contain it, which is the case in about ten percent of people, the disease continues to invade the lung tissue about it. (Ryan 21)
How tuberculosis infects the body is shown in the following chart:
A cough that refuses to go away; perhaps a sudden agonizing pain on breathing that marks the beginning of pleurisy; exhaustion, an unrelievable breathlessness, the appearance of bright red arterial blood in the persistent foul sputum. In others, death arrives in one fell moment; for example when an abscess in the lung or intestine erodes into a major artery. (Ryan 22)
Tuberculosis patients lost weight, were overwhelmingly tired, at times felt overwhelmingly irrational and exuberantly gay, and were anemic. (Dormandy 220)
Tuberculosis could not only be transmitted to another person, it could easily infect other parts of the body. It wasn’t a simple disease that affected everyone in the same way. Almost no organ or tissue in the body was immune.
TB starting in one area of the body could be transmitted to other areas. Once the TB patients began coughing up the TB bacteria, they became contagious and had to be isolated from other non-tubercular persons. As the germ was coughed up, it often lodged in the throat, causing TB laryngitis, which in its last stages reduced speech to a hoarse, agonizing whisper…If the TB germ was swallowed, it could cause overwhelming nausea, almost impossible to alleviate. The patient’s breath often became foul smelling. Abdominal pain, vomiting and diarrhea would be added to the already suffering patient…If the infected material went in the opposite direction, it could impinge on the pleura and start TB pleurisy. This was one of the most feared complications. Not only coughing but the taking of every breath became painful…Disturbed nights turned into nightmares: no pain-killer, not even laudanum or later, morphine, could entirely cope with the pain. The spread of the disease in this way could lead to the dreaded tuberculosis meningitis. (Dormandy 221)
One of the most lethal complications occurs when pus spills into the blood stream and quickly spreads to every organ in the body. Or, it spreads from the lungs or bowel and causes great pain and suffering elsewhere. In the skin and soft tissues it causes disfiguring sores and abscesses; in the internal organs such as the bladder and kidneys it causes an agonizing inflammation…In bones it settles into a protracted and gnawing destructive cavitation and the pus eventually finds its way through the soft tissue to the skin. Tuberculosis has the capacity to infect every internal organ from liver to brain, from the fingertips to the delicate structures of our eyes. (Ryan 23)
Even today, without effective treatment, sixty percent of sufferers will be dead within five years of the onset, their bodies wasted to skeletal proportions, their minds lucidly aware of the life that is being taken from them [emphasis mine]. (Ryan 23-4)
A look at the various types of tuberculosis and how they infect the body.
According to Dormandy, pulmonary tuberculosis was the most common form. (22) The Medical Dictionary definition states:
[P]ulmonary tuberculosis is TB that affects the lungs. Its initial symptoms are easily confused with those of other diseases. An infected person may at first feel vaguely unwell or develop a cough blamed on smoking or a cold. A small amount of greenish or yellow sputum may be coughed up when the person gets up in the morning. In time, more sputum is produced that is streaked with blood. Persons with pulmonary TB do not run a high fever but they often have a low-grade one. They may wake up at night drenched with cold sweat when the fever breaks. The patient often loses interest in food and may lose weight. Chest pain is sometimes present. If the infection allows air to escape from the lungs into the chest cavity (pneumothorax) or if fluid collects in the plural space (pleural effusion) the patient may have difficulty breathing.
The symptoms for pulmonary TB according to The White Death also included “A harsh cough, hoarseness or loss of control of the voice, an audible wheezing, shortness of breath on exertion and coughing up of blood.”… Dormandy then adds “In 80 percent of the cases this form of tuberculosis was fatal in five to fifteen years” [emphasis mine]. (22)
Hester Jane Ervin Howard’s Symptoms
REH’s letters do not indicate any symptoms of wheezing, shortness of breath or coughing up of blood. However, comparing the excerpts from his letters describing his mother’s symptoms against those of tuberculosis, the list is impressive.
Night sweats. On May 13, 1936, REH wrote to H. P. Lovecraft:
She started sweating in January and it’s just the last few days that there has been any appreciable lessening of it. Many a night she had to be changed six or seven times, and that many times a day—sometimes more. Woman after woman we hired and they quit, either worn out by their work, or unwilling to do it, though my father and I did most of it. (Roehm REH Letters 3-460)
Pleurisy—one of the most feared complications was mentioned earlier in the same letter.
She seemed to be improving a little when she had an attack of acute pleurisy on her right side, which until then hadn’t been affected. My father handled that, and she was definitely on the mend, although the sweats never ceased, when in the early part of April we had the worst dust storm I ever saw in my life, and she developed pneumonia.” (3-459)
Also present was the characteristic weight loss.
She is very weak and weighs only 109 pounds—150 pounds is her normal weight and very few kinds of food agree with her; (3-459)
The signature cough was mentioned in the December 5, 1935 letter to HPL.
My parents and I went to Amarillo in the latter part of July. None of us had ever been to that city, and I wanted to see if the high altitude, 4500 feet, might help a persistent cough that had been bothering my mother. (3-382)
From these descriptions plus the aspiration treatments she underwent, (Part 2 “Tuberculosis Operations”) it is probable Hester Jane Ervin Howard contracted pulmonary tuberculosis—a type of TB that “was chronic and even intermittent, with seemingly miraculous remissions and startling improvements followed by terrible relapses.” (Dormandy 22)
The bacterial cause of tuberculosis was discovered by Robert Koch in 1882 who found that it grew and divided much slower than normal bacteria. (Ryan 16) Koch had shown that the tubercle bacillus was a strict aerobe: it could survive but not grow and multiply without a generous supply of oxygen. (Dormandy 221)
After Koch’s discovery the “diagnosis now depended on the presence of the tubercule bacillus in the sputum, not the hollowness of the cough or the loss of weight.” (Rothman 17)
Hester’s diagnosis would have been confirmed by medical tests. No records of any such tests have been discovered. The only written confirmation of her diagnosis is in her death certificate (See right hand column about half way down.) It reads: “chronic ulcerative tuberculosis anemia”
Note: that the term “senility” on her death certificate was used in that era to designate old age rather than lucidity. It appeared often on death certificates of elder persons.
Read the rest of this entry »