Tuberculosis in the Americas, 1870-1945

Beneath the Anguish in Philadelphia and Buenos Aires

Vera Blinn Reber

• Publisher: Routledge
• Year: 2018
• ISBN:
  9780429782787
• Edition: 1
• Topic: Histoire
• Subtopic: Histoire du monde

This book focuses on the era during which the cause of tuberculosis had been identified, and public health officials were seeking to prevent it, but scientists had not yet found a cure. By examining tuberculosis comparatively in two Atlantic port cities, Buenos Aires and Philadelphia, it explores the medical, political and economic settings in which patients, physicians and urban officials lived and worked. Reber discusses the causes of tuberculosis, treatments and public health efforts to stop contagion, and how factors such as gender, age, class, nationality, beliefs and previous experiences shaped patient responses, and often defined the type of treatment.

1 Tuberculosis

Views and Perspectives

If You Have Consumption

1. Be Hopeful and cheerful, for your disease can be cured if you have not neglected it too long.
2. Obey your physician’s instructions. You may improve steadily for months, and then lose it all by carelessness.¹

A person who has had or is likely to have tuberculosis should choose an occupation demanding as little heavy physical labor, anxiety or wearing responsibility as possible, and affording the shortest hours, the most outdoor life or the best ventilation inside, with sufficient remuneration to provide sanitary quarters and plenty of good food.²

From 1870 to 1920, there were revolutionary changes in the western understanding of tuberculosis that resulted in a consensus among physicians and public health officials about the cause, prevention and treatment of tuberculosis. The quotations at the beginning of the chapter are from prize-winning pamphlets that were exhibited in 1908 at the Sixth International Congress on Tuberculosis. These pamphlets represented the efforts of state and local tuberculosis associations to inform the public on how to treat and prevent tuberculosis. They also reflected the consensus among health experts. Although patients considered the information presented in pamphlets, they often found the recommendations difficult to follow. New knowledge does not in itself assure accord and may lead to opposition. Furthermore, following the accepted advice on tuberculosis did not necessarily lead to a cure.

The growing consensus on the cause and treatment of tuberculosis emerged alongside new developments in the medical profession. Physicians and public health professionals organized and supported an increasing number of international conferences and the organization of national tuberculosis associations. American and Western European universities developed similar programs to train physicians. Hospitals became centers of physician training and treatment that provided an alternative option to home care. The growing similarity of medical education in America and Western Europe facilitated the exchange of ideas at international congresses because it assured that physicians spoke the same scientific language. Increased international communications, new organizations, and agreement as to how to train physicians facilitated the growing consensus on the prevention and treatment of tuberculosis.

Between 1870 and 1920, attitudes and policies toward tuberculosis converged in Argentina, the U.S., the Western European nations and nations influenced by the West. In this worldwide movement, Philadelphia and Buenos Aires were both important innovators, exemplifying the changing attitudes and policies. Nations, cities and nongovernmental institutions played key roles in transforming the new knowledge and medical practices in the effort to combat tuberculosis. Yet even with agreements among medical professionals, policies to prevent and treat tuberculosis often emerged slowly and haphazardly. The global public and tubercular patients only slowly accepted the germ theory of disease and that tuberculosis was contagious.

Historical Understandings of Tuberculosis

The history of the western understanding of tuberculosis begins with early Greek manuscripts. The ancient Greeks discussed the nature of the disease and whether it was hereditary or transmittable. They provided clinical descriptions of tuberculosis. Aristotle noted that phthisis (as the Greeks called the disease) was contagious, as did Galen who considered the most important diagnostic sign to be blood in the sputum. (Here, he agrees with early twentieth-century physicians.)³ In the East, Chinese texts described symptoms of pulmonary tuberculosis as early as the western Jin period (265–316). By the twelfth century, Chinese Taoist medical texts viewed pulmonary tuberculosis as infectious in its final stage. The Japanese first described pulmonary tuberculosis in 984. Although eastern efforts to understand tuberculosis paralleled those of the West, the two regions did not influence one another’s ideas before the modern age.⁴

By the seventeenth century, several European governments and cities viewed consumption as contagious and legislated to contain it; in 1669, the Consejo General de Sanidad of the Republic of Lucca (part of the Tuscany region of modern Italy) authorized autopsies and destroyed clothes worn by the deceased tubercular.⁵ In the eighteenth and early nineteenth centuries, European attitudes toward phthisis varied. The French and British came to associate consumption with the literary and intellectual classes and often romanticized the disease in poems, novels and operas while viewing phthisis as hereditary. In contrast, Spaniards and Italians romanticized consumption less and continued to regard it as infectious. As a result, consumptive patients who traveled to warm climates often met hostility.⁶

In 1737, the municipal government of Valencia, Spain, ordered the expropriation of the possessions of those with phthisis. Fourteen years later, the Spanish government extended this directive to the entire country and required an inventory of all goods used by the tubercular, the burning of their clothes and the disinfection of their houses. For example, a Barcelona hotel in which Frederick Chopin had slept asked him to pay for his bed, because a police order required that it be burned. A Spanish patient’s physician was responsible for enforcing these rules, and failure to carry out this responsibility might lead to the suspension of the physician’s license. In Italian cities and the province of Tuscany, clothes of the tubercular were also burned. After the 1821 death of John Keats in Rome, Joseph Severn, who had cared for the poet, had to pay for the burning of the infected furniture in the Piazza di Spagna, and the cleaning and reconditioning of the death chamber.⁷ The Spanish belief about the contagious nature of consumption and the edict of treatment through disinfection was applied to its American colonies. For example, in 1751 and 1752, the Spanish crown issued decrees governing the spread of contagious diseases. The municipality of Buenos Aires applied these decrees in the 1790s to tubercular cases, burning the belongings of the deceased and fumigating their houses. In 1794, the Brothers of Charity of Buenos Aires created a room for infectious patients in the Hospital de Mujeres. With the 1810 establishment of a revolutionary junta, Buenos Aires rejected Spanish colonial policy on tuberculosis.⁸

Throughout much of the nineteenth century, medical professionals in the Americas and Europe debated whether phthisis was hereditary or contagious. Before the acceptance of the germ theory of disease, practitioners and lay people viewed disease in personal terms, assuming that an illness was the result of an individual’s religious, social, hereditary or economic circumstances. Until scientists developed the germ theory of disease and understood how the disease could be transmitted by water, air, food, and human and animal carriers, there was little understanding of infection or the spreading of diseases. In the nineteenth century, diseases were ascribed to “miasma”: foul-smelling air or filthy water and decaying animal or vegetable matter were thought to cause diseases and lead to epidemics. When Edward Livingston Trudeau (1848–1915)—a tuberculosis physician and popularizer of the institution of the sanatorium in the U.S.—attended medical school in 1868, he learned that phthisis was non-contagious, inherited and usually incurable. Attitudes toward the treatment of tuberculosis changed gradually. By 1877, at the American Medical Association meeting in Chicago, the U.S. physicians generally agreed that consumption should be treated in the early stages and that patients benefitted by living in high altitudes.⁹

Modern attempts to bring tuberculosis under control began with Robert Koch’s (1843–1910) 1882 proof of the bacterial nature of the disease. His work—along with that of Louis Pasteur and Joseph Lister—contributed to the modern definition of infection. Koch announced the identification of the tuberculosis bacillus on 24 March 1882 in his paper “On the Aetiology of Tubercular Disease,” which was read to the Physiological Society in Berlin. The paper’s publication was noted in an editorial in the medical journal Lancet on 22 April and in the New York World on 23 April 1882. The more politically conservative Philadelphians were slower than the residents of New York, Boston and Baltimore to accept the germ theory of disease and Koch’s explanation of the cause of tuberculosis.¹⁰ In spite of Koch’s discovery, physicians, hygienists and practitioners continued to debate the degree of contagiousness of tuberculosis. Many Philadelphia and Buenos Aires physicians were unconvinced that Koch had found the cause; and only with the translation of his paper from German into English in 1884 did the U.S. medical establishment seriously consider his discovery. Leading medical colleges continued to propagate contradictory doctrines.¹¹

During the 1870s, health professionals and the elite classes in the U.S., Argentina and Europe incorrectly associated tuberculosis with moral degradation—alcoholism and prostitution—thought to be caused by the new urban social order. For example, Gabriela de Laperriére de Coni, an Argentine social worker, was concerned with how the life and work of women and children influenced their health. She emphasized six contributors to pulmonary tuberculosis: alcoholism, unhealthy housing, deficient alimentation, excessive physical labor, poor hygiene, and moral and intellectual degradation.¹² In 1869, James Copland, a British physician, listed eighteen causes of consumption resulting from deviations from culturally accepted lifestyles. For example, he suggested that individuals were most inclined to consumption if exposed to cold air and damp clothes; if they had too many sexual partners, masturbated, or were celibate; women might contract consumption if they suffered physical abuses or rode astride horses rather than sidesaddle.¹³

The standard nineteenth-century European medical texts and dictionaries continued to emphasize that tuberculosis was a hereditary disease, whose onset was spurred by leading a sedentary, indoor life.¹⁴ William Osler’s original 1892 edition of The Principles and Practices of Medicine defined tuberculosis as “an infective disease, caused by the bacillus tuberculosis.” The author further noted that “Tuberculosis unquestionably may be inherited, but in what way and how often are unsettled problems.” This text, which went through multiple editions between 1892 and 1947, did not change its basic definition until the eighth edition in 1921. In 1895, however, the author muted his comments on the hereditability of tuberculosis, noting that “in extremely rare instance the disease is congenital.”¹⁵ As late as 1904, Lippincott’s Medical Dictionary declared that pulmonary consumption was caused by heredity, family predisposition, sudden changes of weather, and “above all the presence of the tubercle bacillus.”¹⁶ Increasingly, conflicts over causes of tuberculosis were no longer along national lines but among specialists. Hygienists and sanitationists tended to view tuberculosis as communicable and spread by the poor and the working class; physicians and medical researchers continued to debate whether tuberculosis was inherited or contagious and the role of climate in causing, preventing and curing tuberculosis. These conflicts reflected contrasting political visions of how to use science to create a superior society.

Lawrence F. Flick (1856–1938),¹⁷ who graduated from Jefferson Medical College of Philadelphia in 1879, focused his practice on tuberculosis patients. He never viewed tuberculosis as hereditary but did accept that an individual could be predisposed to it. Initially, he falsely saw the stomach as the usual mode of entrance of the bacilli and believed that there was little danger of contracting the disease through the lungs. As late as 1902, he observed no evidence that tuberculosis could be transmitted to human beings through milk and meat, suggesting that development of tuberculosis in children who drank milk from tubercular cows was purely coincidental. On the other hand, Flick correctly viewed climate as insignificant in preventing and curing tuberculosis, because the disease existed in all climates. Like many physicians of his day, Flick originally had an incomplete understanding of the causes of tuberculosis. Eventually, Flick’s research, experience with patients and attendance at international conferences led him to become among the first Philadelphia physicians to accept that tuberculosis was an infectious disease caused by a microorganism.¹⁸

Flick had many heated discussions with his colleagues on the topic. To prove to other physicians that tuberculosis was contagious, he conducted a twenty-five-year study of tuberculosis in the fifth ward of the city of Philadelphia, a mostly poor immigrant community (twenty percent of whose residents were African-American). With mortality information provided by physicians and undertakers to the Board of Health, Flick located the phthisis cases on a map to show that cases appeared in the same houses and apartment buildings; less than ten percent of the cases were isolated. His evidence, presented to various professional groups, demonstrated not only that tuberculosis was contagious but also that houses in which the disease occurred remained a center of infection for an indefinite period. Flick’s recommendations, correlating with international efforts, emphasized that the homes of tubercular individuals should be registered, so that health officials could track those who were ill.¹⁹

Argentine physicians, like their U.S. counterparts, debated the specific causes of tuberculosis and often agreed that it was difficult to prove the importance of any single factor. Some physicians argued that tuberculosis was hereditary, while others contended that the main culprits were factors such as climate, poor hygiene, an inadequate diet, crowded housing, poverty and lifestyle.²⁰ Debates over w...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• Dedication
• List of Figures
• List of Tables
• Acknowledgments
• Introduction: Beneath the Anguish: Tuberculosis, 1870–1945
• 1 Tuberculosis: Views and Perspectives
• 2 Two Cities and Their Medical Establishments: Buenos Aires and Philadelphia, 1870–1945
• 3 Immigrants, Migrants and Public Health Policies in Buenos Aires and Philadelphia
• 4 Tuberculosis Treatment in Buenos Aires and Philadelphia: Patient and Physician Experiences
• 5 The Sanatorium Age: Argentina and Pennsylvania
• 6 Poor and Ill: Children of Buenos Aires and Philadelphia
• 7 Tuberculosis in Global and Comparative Perspective
• Epilogue: Tuberculosis Developments and Patient Experiences
• Glossary of Medical Terms
• Bibliography
• Index