up its fumes, whether he likes it or not. by the time all charms are used up, the smoke should also be dispersed. it may be difficult for the patient to bear the odour of the smoke at first, but once he gets used to such a smell, it does not really matter. whenever the patient feels that there is phlegm in his throat, he is advised to cough and spit it out. if the patient is greatly affected by the symptoms, it will be good if his spittle is thick and if he can spit it out. when the patient is less affected by the wicked ch'i, he does not have much phlegm to eject, but if he is deeply affected, he tends to vomit and to expectorate heavily until everything is cleared up, and then his illness is cured. when the wicked element is rooted out, it does not need to be fumigated any more . in addition, daoist healers would burn talismans in order to fumigate the clothes and belongings of the deceased, and would warn the tuberculosis patient's family to throw away everything into a changliu shui 長流水 "everflowing stream". according to liu ts'un-yan, "this proves that the priests of the time actually wanted to destroy all the belongings of the deceased, using charms as a camouflage." classical antiquity hippocrates. hippocrates, in book 1 of his of the epidemics, describes the characteristics of the disease: fever, colourless urine, cough resulting in a thick sputa, and loss of thirst and appetite. he notes that most of those affected became delirious before they died from the disease. hippocrates and many other at the time believed phthisis to be hereditary in nature. aristotle disagreed, believing the disease was contagious. pliny the younger wrote a letter to priscus in which he details the symptoms of phthisis as he saw them in fannia: the attacks of fever stick to her, her cough grows upon her, she is in the highest degree emaciated and enfeebled.— pliny the younger, letters vii, 19 galen proposed a series of therapeutic treatments for the disease, including: opium as a sleeping agent and painkiller; blood letting; a diet of barley water, fish, and fruit. he also described the phyma (tumor) of the lungs, which is thought to correspond to the tubercles that form on the lung as a result of the disease. vitruvius noted that "cold in the windpipe, cough, plurisy, phthisis, spitting blood", were common diseases in regions where the wind blew from north to northwest, and advised that walls be so built as to shelter individuals from the winds. aretaeus was the first person to rigorously describe the symptoms of the disease in his text de causis et signis diuturnorum morborum: voice hoarse; neck slightly bent, tender, not flexible, somewhat extended; fingers slender, but joints thick; of the bones alone the figure remains, for the fleshy parts are wasted; the nails of the fingers crooked, their pulps are shrivelled and flat...nose sharp, slender; cheeks prominent and red; eyes hollow, brilliant and glittering; swollen, pale or livid in countenance; the slender parts of the jaws rest on the teeth as, as if smiling; otherwise of cadaverous aspect...— de causis et signis diuturnorum morborum, aretaeus, translated by francis adams in his other book de curatione diuturnorum morborum, he recommends that affected individuals travel to high altitudes, travel by sea, eat a good diet and drink plenty of milk. pre-columbian america in south america, reports of a study in august 2014 revealed that tb had likely been spread via seals that contracted it on beaches of africa, from humans via domesticated animals, and carried it across the atlantic. a team at the university of tübingen analyzed tuberculosis dna in 1,000-year-old skeletons of the chiribaya culture in southern peru; so much genetic material was recovered that they could reconstruct the genome. they learned that this tb strain was related most closely to a form found only in seals. in south america, it was likely contracted first by hunters who handled contaminated meat. this tb is a different strain from that prevalent today in the americas, which is more closely related to a later eurasian strain. prior to this study, the first evidence of the disease in south america was found in remains of the arawak culture around 1050 bc. the most significant finding belongs to the mummy of an 8 to 10-year-old nascan child from hacienda agua sala, dated to 700 ad. scientists were able to isolate evidence of the bacillus. europe: middle ages and renaissance during the middle ages, no significant advances were made regarding tuberculosis. avicenna and rhazes continued to consider to believe the disease was both contagious and difficult to treat. arnaldus de villa nova described etiopathogenic theory directly related to that of hippocrates, in which a cold humor dripped from the head into the lungs. in medieval hungary, the inquisition recorded the trials of pagans. a document from the 12th century recorded an explanation of the cause of illness. the pagans said that tuberculosis was produced when a dog-shaped demon occupied the person's body and started to eat his lungs. when the possessed person coughed, then the demon was barking, and getting close to his objective, which was to kill the victim. royal touch henry iv of france touching numerous sickly individuals during the ceremony of the "royal touch". the original caption reads: des mirabili strumas sanandi vi solis galliae regibus christianissimis divinitus concessa liber unus. monarchs were seen as religious figures with magical or curative powers. it was believed that royal touch, the touch of the sovereign of england or france, could cure diseases due to the divine right of sovereigns. king henry iv of france usually performed the rite once a week, after taking communion. so common was this practice of royal healing in france, that scrofula became known as the "mal du roi" or the "king's evil". initially, the touching ceremony was an informal process. sickly individuals could petition the court for a royal touch and the touch would be performed at the king's earliest convenience. at times, the king of france would touch affected subjects during his royal walkabout. the rapid spread of tuberculosis across france and england, however, necessitated a more formal and efficient touching process. by the time of louis xiv of france, placards indicating the days and times the king would be available for royal touches were posted regularly; sums of money were doled out as charitable support. in england, the process was extremely formal and efficient. as late as 1633, the book of common prayer of the anglican church contained a royal touch ceremony. the monarch (king or queen), sitting upon a canopied throne, touched the affected individual, and presented that individual with a coin – usually an angel, a gold coin the value of which varied from about 6 shillings to about 10 shillings – by pressing it against the affected's neck. although the ceremony was of no medical value, members of the royal courts often propagandized that those receiving the royal touch were miraculously healed. andré du laurens, the senior physician of henry iv, publicized findings that at least half of those that received the royal touch were cured within a few days. the royal touch remained popular into the 18th century. parish registers from oxfordshire, england include not only records of baptisms, marriages, and deaths, but also records of those eligible for the royal touch. contagion girolamo fracastoro became the first person to propose, in his work de contagione in 1546, that phthisis was transmitted by an invisible virus. among his assertions were that the virus could survive between two or three years on the clothes of those with the disease and that it was usually transmitted through direct contact or the discharged fluids of the infected, what he called fomes. he noted that phthisis could be contracted without either direct contact or fomes, but was unsure of the process by which the disease propagated across distances. paracelsus's tartaric process paracelsus advanced the belief that tuberculosis was caused by a failure of an internal organ to accomplish its alchemical duties. when this occurred in the lungs, stony precipitates would develop causing tuberculosis in what he called the tartaric process. seventeenth and eighteenth centuries franciscus sylvius began differentiating between the various forms of tuberculosis (pulmonary, ganglion). he was the first person to recognize that the skin ulcers caused by scrofula resembled tubercles seen in phthisis, noting that "phthisis is the scrofula of the lung" in his book opera medica, published posthumously in 1679. around the same time, thomas willis concluded that all diseases of the chest must ultimately lead to consumption. willis did not know the exact cause of the disease but he blamed it on sugar or an acidity of the blood. richard morton published phthisiologia, seu exercitationes de phthisi tribus libris comprehensae in 1689, in which he emphasized the tubercle as the true cause of the disease. so common was the disease at the time that morton is quoted as saying "i cannot sufficiently admire that anyone, at least after he comes to the flower of his youth, can dye without a touch of consumption." in 1720, benjamin marten proposed in a new theory of consumptions more especially of phthisis or consumption of the lungs that the cause of tuberculosis was some type of animalcula—microscopic living beings that are able to survive in a new body (similar to the ones described by anton van leeuwenhoek in 1695). the theory was roundly rejected and it took another 162 years before robert koch demonstrated it to be true. in 1768, robert whytt gave the first clinical description of tuberculosis meningitis and, in 1779, percivall pott, an english surgeon, described the vertebral lesions that carry his name. in 1761, leopold auenbrugger, an austrian physician, developed the percussion method of diagnosing tuberculosis, a method rediscovered some years later in 1797 by jean-nicolas corvisart of france. after finding it useful, corvisart made it readily available to the academic community by translating it into french. william stark proposed that ordinary lung tubercles could eventually evolve into ulcers and cavities, believing that the different forms of tuberculosis were simply different manifestations of the same disease. unfortunately, stark died at the age of 30 (while studying scurvy) and his observations were discounted. in his systematik de speziellen pathologie und therapie, j. l. schönlein, professor of medicine in zurich, proposed that the word "tuberculosis" be used to describe the condition of tubercles. the incidence of tuberculosis grew progressively during the middle ages and renaissance, displacing leprosy, peaking between the 18th and 19th century as field workers moved to the cities looking for work. when he released his study in 1808, william woolcombe was astonished at the prevalence of tuberculosis in 18th-century england. of the 1,571 deaths in the english city of bristol between 1790 and 1796, 683 were due to tuberculosis. remote towns, initially isolated from the disease, slowly succumbed. the consumption deaths in the village of holycross in shropshire between 1750 and 1759 were one in six (1:6); ten years later, 1:3. in the metropolis of london, 1:7 died from consumption at the dawn of the 18th century, by 1750 that proportion grew to 1:5.25 and surged to 1:4.2 by around the start of the 19th century. the industrial revolution coupled with poverty and squalor created the optimal environment for the propagation of the disease. nineteenth century epidemic tuberculosis in the 18th and 19th century, tuberculosis (tb) had become epidemic in europe, showing a seasonal pattern. in the 18th century, tb had a mortality rate as high as 900 deaths (800–1000) per 100,000 population per year in western europe, including in places like london, stockholm and hamburg. similar death rate occurred in north america. in the united kingdom, epidemic tb may have peaked around 1750, as suggested by mortality data. in the 19th century, tb killed about a quarter of the adult population of europe. in western continental europe, epidemic tb may have peaked in the first half of the 19th century. in addition, between 1851 and 1910, around four million died from tb in england and wales – more than one third of those aged 15 to 34 and half of those aged 20 to 24 died from