Taming Infection: The American Response to Illness from Smallpox to Covid

By Gregg Coodley and David Sarasohn

"A clearly written, information-rich guide to the impact of infectious diseases on the United States and our responses to each of them. Coodley and Sarasohn demonstrate how science and public health have had to counter fear, ignorance and hubris-along with the microbes themselves-in battles that reached a desultory climax with our misbegotten re

• Language: English
• Publisher: Atmosphere Press
• Release date: Jun 21, 2022
• ISBN: 9781639884780

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More Reviews of Taming Infection

Timely, thorough, and thought-provoking, Taming Infection is a history of America’s pandemics from smallpox to COVID. Written by a physician and an historian, it shows a repeating pattern of conflict between scientific advances and pushback that challenged testing, vaccines, lockdowns, and other public health measures. Taming is a must read for politicians, policymakers, and the public who need to understand the history of American epidemics in order to plan and guide our response to inevitable future epidemics.

—Dr. Robert Liebman

Gregg Coodley’s complete, interesting and enormously en-lightening review of the major infectious diseases affecting the United States and the entire globe over the past three centuries should be required reading for both high school seniors and college freshmen. It is most certainly a tale of lessons not learned, not only by Americans, but the rest of the world regarding potential viral carnage. In our case, the take home message, unfortunately, is that although Americans’ collective memories of these events and outcomes might be good, they’re very short.

—Dr. Barry Albertson

"Taming Infection is a must read for those of us who daily wonder how long we must live with the Covid 19 pandemic. You will learn that a fearsome list of diseases such as tuberculosis, malaria, yellow fever, and cholera that were once endemic to the United States were greatly mitigated or eradicated entirely by public health measures that prevented their spread.

If you are incredulous at those today who abjectly refuse to use vaccines or wear masks, you may be strangely consoled to discover that we have no corner on irrationality or lack of compassion. We learn that in Hungary in 1831 mobs killed doctors amid rumors that they were being paid for each death, while in 1854, the Times of London editorialized that, we prefer to take our chances with cholera and the rest than be bullied into health. In Alleghany, Pennsylvania the dead were thrown overboard on river ships, and the sick were dumped ashore and left to die.

The penultimate chapter provides a welcome review of our response to Covid 19—its successes and missteps. In the final chapter the authors turn to history and ultimately toward the future, taking a broad view of our relationship to disease. Taming Infection could not be more timely, and it deserves a wide readership."

—Stephen Karakashian, Co-Author, Redeeming the Past:

My Journey from Freedom Fighter to Healer

Reviews of The Green Years 1964-76: When Democrats and Republicans United to Repair the World

by Gregg Coodley and David Sarasohn

"The Green Years is vivid, thoroughly researched and authentic. Brings you into that era. Absorbing and full of insights."

—Michael McCloskey, executive director(retired) ,Sierra Club

"As we face the crisis of climate change, this important history of earlier environmental legislation helps us remember that organized movements can persuade even the most recalcitrant politicians to reshape their legislative agendas. The Green Years is a very compelling story."

—Barbara Dudley, former executive director, Greenpeace USA

"This book is an ambitious narrative history of environmental politics and policy in the 1960s and 1970s. The Green Years is the most comprehensive history of environmentalism’s legislative achievements during its most fruitful period."

—Robert D. Lifset, author of Power on the Hudson: Storm King Mountain and the Emergence of Modern American Environmentalism

"The Green Years, 1964-76: When Democrats and Republicans United to Repair the Earth is timely because it clearly lays out for America now how earlier generations came together to pass landmark legislation…their book is indispensable because it shows how people and policy prevailed for the common good from 1964-76…it will be in my Senate office in Washington, DC, to serve as an essential resource for my staff and me to draw from as the work continues each day to fight climate change and build on the environmental achievements from the exceptional twelve-year era covered so comprehensively and accessibly in this book."

—Senator Ron Wyden (D-OR) (from forward to The Green Years)

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© 2022 Gregg Coodley and David Sarasohn

ISBN 978-0-9990770-2-3

Published by Atmosphere Press

Cover design by Ronaldo Alves

No part of this book may be reproduced without permission from the author except in brief quotations and in reviews.

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Dedicated to Karen Coodley and Lisa Sarasohn

ACKNOWLEDGEMENTS

We would want to note the crucial role of the Multnomah County Library in aiding the research for this book. All the staff at the Hillsdale Library were amazingly supportive and helpful. We also could not have succeeded without the Library’s interlibrary loan program. We were fortunate enough to have utilized it before it was shut down due to the Covid pandemic.

Lauren Coodley was invaluable throughout the process, offering advice and encouragement. Cheryl and Nora Coon both offered their time and valuable feedback.

Yet again, the technical wizardry of Danny Henderson was essential in the book’s production. We want to thank Michael Beilstein for his many hours of work and corrections on the endnotes.

We wanted to thank our agent Susan Schulman for working so much on the publication of the book.

The staff of Atmosphere Press was of wonderful assistance. We wanted to thank, in particular, Kyle McCord, Nick Courtright, Ronaldo Alves, Albert Liau, Chris Beale, Alex Kale, Erin Larson, and Cassandra Felten for their input and assistance in the production of this book.

We appreciate the support of our children, Sam, Scout, Sarah, David and Mimi, and Alex and Peter, for their understanding of the time and effort that has been necessary for authoring this book. Finally, we want to thank our wives, Karen Coodley and Lisa Sarasohn, to whom this book is dedicated.

Table of Contents

Preface

Introduction

Chapter 1: Tuberculosis

Chapter 2: Malaria

Chapter 3: Yellow Fever

Chapter 4: Smallpox

Chapter 5: Typhoid Fever

Chapter 6: Cholera

Chapter 7: Typhus

Chapter 8: Syphilis

Chapter 9: Influenza

Chapter 10: AIDS

Chapter 11: Measles

Chapter 12: Plague

Chapter 13: Diphtheria

Chapter 14: Pneumococcus

Chapter 15: Covid-19

Chapter 16: Epilogue: Hubris and Folly: Prospects for the Future

PREFACE

The genesis of this book occurred in November 2019. David Sarasohn and I had completed writing our environmental history, The Green Years: When Democrats and Republicans United to Repair the Earth. It would take two more years before the University Press of Kansas published this book in September 2021.

As such, I was looking to find a new project. My full-time job is as a primary care physician. Starting in 1988, I became involved in the care of AIDS patients. When I joined the faculty of the Oregon Health Sciences University in 1990, I added clinical research in AIDS to my care of patients. My particular interest and area of publications was in the interface of AIDS and nutrition. Thus, the subject of infectious disease had long been of interest to me. I continued taking care of AIDS patients and doing clinical research even after moving into private practice at the Fanno Creek Clinic in 1997.

I decided that my next book project could combine medicine and history. There are many previously published excellent medical history books dealing with infections. Most deal with a single disease. Those that deal with multiple diseases have a worldwide focus. I could not find a book that focused on a complete range of infectious diseases and their particular history in the United States. This book aimed to fill that gap by discussing fifteen major infectious diseases that have impacted the United States during our history. In re-searching the book, I was astonished to learn how much of an impact these infections have had on Americans and American history.

When I started working on the book just prior to Thanksgiving, 2019 I had no idea that I would soon be dealing as a doctor with a new pandemic. However, even while re-searching and drafting this book, I have had to deal with Covid-19 in my medical practice. It has been a challenging period, with financial stress on the Fanno Creek Clinic and personal stress upon all the staff. We have had staff members become ill with Covid, and patients die from it. The pandemic, while recently waning in the United States, persists.

I was incredibly fortunate to be able to again interest David Sarasohn in authoring the book with me. David is a brilliant writer and brings an amazing knowledge of history and extensive experience as a journalist to the project. David was a long-time columnist and editor at the Oregonian newspaper. He makes any project he engages in look better.

The book that follows results from our collaboration.

Gregg Coodley

October 2021

INTRODUCTION

They have killed and maimed more than all of the nation’s wars put together. Even in wars they were the greatest killers. Among the millions of viruses and bacteria that make up most life on Earth, there are a few, a very few that have been notable for their efficacy in killing and sickening humans. They have shaped American history more than most people realize. While most Americans give humans both credit and blame for the great developments in American history, these tiny microbes have been far more consequential than is known. American bacteriologist Hans Zinsser wrote, Swords and lances, arrows, machine guns, and even high explosives have had far less power over the fate of nations than the typhus louse, the plague flea, and the yellow fever mosquito.¹

However, it has only been since the late 19th century that humans were aware of these organisms, let alone their link to disease. Nearly two thousand years earlier, a Roman, Marcus Terentius Varro postulated that tiny invisible animals could cause contagion, noting that swampy places might be filled with animals that floated on the air and entered into the nose and mouth. His ideas were forgotten until the invention of the microscope allowed humans to see bacteria for the first time, but their role in disease was still unknown. Jacob Henle, in his work On Miasmata and Contagia in 1840, argued that these tiny living organisms caused contagious diseases.² The prevailing theory still held that miasmas, or bad air from swamps and other foul places, was the cause of disease. It would take the work of Louis Pasteur and Robert Koch in the late 19th century to prove the germ theory of disease, that infections were due to these microorganisms.

For any infectious disease, infection, defined as a microbe entering a host, is necessary for disease, but most infections don’t cause disease. Historian Arno Karlen noted, The fate of most microbes that invade is quick death.³ Why some infections cause disease depends both on the microbe and the host.

Microbes often prefer particular host species. Of the one million-plus known microbes, only a little less than 1400 cause human disease.⁴ One of the largest sources of human diseases are microbes that caused diseases in domesticated animals and, at some point, adapted to become human diseases. These include tuberculosis, typhoid, typhus, and influenza. Historian William McNeill wrote, In addition to diseases derived from or shared with domesticated animals, human populations may become diseased by intruding upon one or another disease cycles established among wild animals.⁵ Examples include plague and yellow fever. McNeill added, Disease-producing parasites were quite as successful as people in taking advantage of new opportunities for occupying novel ecological niches that opened up as a result of human actions.⁶ For example, the clearing of forests for agriculture in Africa allowed the malaria-carrying mosquito anopheles gambiae to spread, resulting in increased malaria.

There are other diseases that are only found in humans. These require a critical mass of people for the microbe to perpetuate itself. McNeill noted, Infectious bacterial and viral diseases that pass directly from human to human with no intermediate host are therefore the diseases of civilizations (and cities) par excellence.⁷ Thus measles and smallpox, which induce immunity after an infection, required cities of a certain size, estimated to be 300,000-500,000 people, in order to not die out.⁸ Karlen wrote, Each of the four major types of disease transmission – airborne, waterborne, direct contact and by insects to other vectors – was enhanced by urban life.⁹

While urban civilizations were weakened by endemic infections, these infections, by eventually inducing immunity in much of the population, also gave them a crucial advantage against bordering peoples without an experience of or immunity to such organisms. This may have been a crucial factor in allowing the early civilizations to spread and grow.

The degree of infectiousness of each organism is defined by its R number, the average number of new cases infected by each patient in a susceptible population. When the R<1, the disease is not self-sustaining. Typically, the R level may be high at the beginning of an epidemic and then fall as there are less susceptible people to become newly infected.¹⁰ Tuberculosis has an R of 4-5, meaning each TB patient infects, on average, 4-5 others. For HIV, the R is 10-12.¹¹ Notably, many of those infected with certain diseases may be largely asymptomatic but may still be capable of spreading the infection to others.¹²

Transmission of microbes from one animal to another can occur in a wide variety of manners. Direct transmission can come for some microbes through sexual intercourse, while others are spread by respiratory droplets (usually up to a meter away). Indirect transmission can take the form of microbes hiding in a carrier vehicle, such as food, or by means of outside vector, of which the mosquito is the most notorious. Other organisms, including some that live in the soil, can be aerosolized and spread through the wind to a much greater distance than that of droplets from an infected person.

Infection requires that a minimum number of microbes must survive to propagate within the animal. Certain microbes may colonize a host without causing disease. When a change in circumstances causes these organisms to cause disease, this is called an endogenous infection. Disease caused by microbes new to the host is called an exogenous infection.

Two other definitions are useful. Virulence refers to the number of cases of severe infection compared to the number of people infected. The case fatality rate refers to the number of deaths compared to the number of people infected.

Microbes that are so virulent that they kill the host before they have a chance to spread beyond the host, do not create ongoing diseases. On the other hand, microbes that are not virulent enough may be killed by the host immune system. For disease-causing organisms, they have evolved to find the place in between where they prosper and propagate. Historian William McNeill wrote, Prolonged interaction between host and infectious organisms, carried across many generations and among suitably numerous populations on each side, creates a pattern of mutual adaptation which allows both to survive.¹³

The virulence of an organism in any animal has a lot to do with the immune status of the host. The biggest, but certainly not the only factor in a host’s immune status is age. The vast majority of disease-causing microbes cause the worst disease in the very young, whose immune system is not complete, and the very old, whose immune system has weakened.

It is worth noting that many microbes protect us from disease. The four hundred plus species of bacteria inhabiting the human gut may prevent more virulent organisms from gaining a foothold. They also aid digestion and help boost our immune system. Estimates are that the average human body is composed of about forty trillion bacterial cells and thirty trillion human cells.¹⁴

In addition, diseases usually become less virulent over time in order that the infectious organism not die off. Karlen stated, Fatal or severe disease is usually a sign that host and parasite are relatively new acquaintances.¹⁵ Zinsser wrote, Diseases have changed within a relatively short period of time. Scarlet fever has become definitely milder…the same is true of measles and diphtheria…the change began well before modern preventive methods had exerted any noticeable influence.¹⁶

Some of the most harmful organisms seem like they belong to a different age and country, such as smallpox and yellow fever. Other microbes Americans now associate mainly with nations of the developing world, such as malaria and cholera, forgetting that they were once a plague in our nation as well. We think about measles as a mild, easily preventable childhood disease, but it was once far more fearsome. Tuberculosis once was as ubiquitous and fearsome as cancer is today. There are other organisms that few people outside the health care community have even heard of, such as streptococci pneumoniae, yet which is the leading cause of pneumonia, sepsis, and bacterial death in the United States.

As humans struggled and perished from the diseases these tiny murderers induced, their body’s immune systems evolved to protect them from disease. Scientist Michael Kinch noted their astonishing versatility of the human immune system, writing, Each of us contains the potential to recognize all potential types of foreign invaders.¹⁷

Humans also took collective steps to fight back. Some of these involved public health measures. For specific infections, we found antibiotics, wonder drugs that quickly overcame the invading organism. For others, humans devised vaccines, effectively preventing infections.

Yet, as the microbiologist Rene Dubos wrote, Threats to health are inescapable accompaniments of life.¹⁸ Even as humans appeared to triumph, the bacteria and viruses, in many cases, countered the human achievements. Not out of malice, but through a Darwinian process that selected those organisms that were able to survive the human weapons. Bacteria and viruses mutated, in some cases adopting from each other tricks that enable them to avoid the human defenses. Other diseases had a resurgence when humans forgot their horrible costs. Vaccines were foolishly dismissed as an option with marginal benefits, leading to the reappearance of diseases once largely eliminated from the country.

Now the nation and the world are confronting a new menace in the Covid-19 virus. Its story is still unfinished.

This is the story of the infections that have most tormented Americans and their impact on American history. In telling their stories, we see a frequently repeating pattern in the American response to each microbe. Initially, our response is unsure with treatments based on ignorance. Often, we have scapegoated a part of the community as the source of the evil. Finally, as we have learned more and become more organized, we have responded to tame the infections. Of these fearsome infections, some are indeed vanquished, others still unconquered, and some once conquered, but perhaps not forever.

A house on a hill Description automatically generated with low confidence

Oregon State Tuberculosis Hospital, 1913

(courtesy Wiki Commons)

Chapter 1

Tuberculosis

Harriet knew she had tuberculosis.

I began to cough, and first mouthful I knew from the look and feeling was blood, the daughter of famed lexicographer Noah Webster wrote her sister, ... (I) became convinced that if I could keep from further coughing, I should be able to wait till morning without disturbing anyone. As soon as morning arrived, I looked at the contents of my cup. Alas, my fears were realized.¹⁹

The night was the start of Harriet Webster Fowler’s five-year descent to death by tuberculosis.

Tuberculosis is one of the oldest human diseases, as well as one of the deadliest, with a casualty list of a billion people just over the last two centuries.²⁰ It has been called phthisis, consumption, and TB, but its formal name is Mycobacterium tuberculosis.

Tuberculosis is older than humanity, afflicting multiple millennia of mammals, as well as birds, fish and reptiles.²¹ Evidence of its infection has been found in the remains of Homo Erectus, an ancestor of modern humans.²² Signs of its deadly presence have been found in five-thousand-year-old remains in Egypt, and art of the time prominently showed spinal tuberculosis causing a hunchback. Tuberculosis appears in 2700-year-old relics in Peru and in the lungs of Peruvian mummies dating to 1000-1300 A.D.²³

Modern research suggested that tuberculosis required a certain mass of humans, at least two hundred to four hundred people living together, to sustain itself.²⁴

From very early on, it was called consumption, for the way it seemed to consume the body. In Deuteronomy, Moses tells the Israelites that if they ignore God’s commandments, The Lord will smite you with consumption.²⁵

Ancient India had a hymn dedicated to the cure of yakshma, apparently TB, described as worsened by fatigue, sorrow, fasting, and pregnancy – medical advice also heard from modern physicians. The Ordinances of Manu from 1300 B.C., warned against marrying into a family with tuberculosis. In 500 B.C.E., the famous Indian chronicle reportedly by Sushruta Samhita warned physicians against treating TB patients since the disease was incurable.²⁶

Chinese medical texts from the 3rd century B.C. discuss a chronic wasting disease, chiai nio, with patients spitting up blood.²⁷ This was also tuberculosis.

To Hippocrates in the 5th century B.C., Consumption was the most considerable of the diseases which then prevailed and the only one which proved fatal to many persons. Most of them were affected … in the following manner: fevers… constant sweats… sputa, small, dense, concocted but brought up rarely and with difficulty… they were soon wasted.²⁸ The Greeks named it phthisis, dwindling or wasting away.²⁹

These ancient physicians noted several features of the disease. It could affect multiple parts of the body, but most commonly the lungs, and worked at different rates in different people. A 7th century B.C. tablet from Mesopotamia comments on a patient, What he coughs up is thick and frequently bloody. His breath sounds like a flute.³⁰ The Greek physician Areteus wrote in the 2nd century that, Hemorrhage from the lungs is particularly dangerous.³¹ Galen defined phthisis as Ulceration of the lungs, thorax or throat, accompanied by a cough, fever, and consumption of the body by pus, and thought it infectious.³² Yet, the cause of the disease, let alone an effective treatment, remained completely unknown.

Tuberculosis continued to plague humanity as the centuries went on. The writer John Bunyan called it, The captain of all these men of death.³³ While patients and doctors noted the common symptoms of cough, fever, night sweats, and weight loss, the cause remained mysterious.

Tuberculosis is caused by a tiny bacterium named Mycobacterium tuberculosis. Tuberculosis is usually spread from person to person through airborne transmission from coughing or talking. Patients with tuberculosis expel water droplets containing the bacterium that can remain in the air for several hours until inhalation brings it into the lungs of its next victim.

Health care workers were traditionally at increased risk. Early in the 20th century, studies showed that forty percent of medical and nursing students became infected during their training, with one in twenty developing active TB.³⁴

Most tuberculosis infections begin in the lungs, and the organisms spread into the bloodstream. In about four to six weeks, the body fights back, and specialized T white blood cells act to destroy the TB bacteria – but can’t always completely eradicate it from the body.³⁵ Five to eight percent of patients with initial tuberculosis infections develop clinical disease.³⁶

Initial symptoms may involve loss of appetite, lassitude, weight loss, night sweats, and a cough. As pulmonary tuberculosis progresses, patients may have hoarseness, increasing shortness of breath, slight fever, and finally cough up blood.³⁷ Without treatment, sixty percent of those with active disease would die within five years.³⁸

In immunocompromised patients, TB can spread rapidly. HIV, by destroying the T cells vital for defense, is one of the strongest risk factors for rapid spread. Other patients with less-than-optimal immune systems, such as the very young and the elderly, are also more likely to have rapidly progressive tuberculosis, historically called galloping consumption.³⁹ Poor nutrition can also contribute to decreased immune function and more rapid disease. In contrast, children ages five to fifteen have the greatest resistance to disease.⁴⁰

In the majority of patients, the body’s immune system will cause tuberculosis to be dormant for years, and never re-activate. In only five percent of patients, tuberculosis will eventually begin to multiply to cause what is called reactivation disease.⁴¹

If the disease progresses again, patients may have minimal or no symptoms initially, but will eventually develop fever, fatigue and cough, with shortness of breath, sputum production, and coughing up blood.

While most tuberculosis is centered in the lungs, it can affect multiple organs, including kidneys, stomach, female and male genital systems, bones, and the central nervous system.⁴² Bone infection can cause bone erosion and collapse, particularly in the spinal column.⁴³ Tuberculous abscesses would cause softening and collapse of vertebrae, occasionally compressing the spinal cord, causing paralysis and death.⁴⁴ Miliary disease occurs when tuberculosis spreads through the blood to infect multiple organs.

The one saving grace of tuberculosis is that it is not easily spread. Most transmission is to the household contacts of the infected patient.⁴⁵

A disease so widespread created a plethora of suggested treatments. Claudius Galenus prescribed milk, rest and residence underground. Pliny advised eating wolf’s liver boiled in wine. Another Roman idea was to bathe in the urine of some-one who had eaten cabbage.⁴⁶ A Hindu physician recommended living out of doors and exercise.⁴⁷ The Middle Ages saw weasel’s blood and pigeon’s dung recommended.⁴⁸ In the 14th century, John of Gaddesden recommended human milk, specifying, the best is the milk of a young brunette after her first child.⁴⁹

In 1689 the leading textbook, Morton’s Phthisologia, recommended bloodletting as very beneficial in the beginning of consumption, while also suggesting emetics, cathartics, diuretics, and heat to induce sweating.⁵⁰ Dr. Edward Berry wrote in 1721 that since TB was due to an excess of meat and alcohol, it could be fought with a diet of milk and vegetables.⁵¹ In 1742 famed English physician Thomas Sydenham advised, The principal assistant in the cure of this disease is riding on horseback every day.⁵²

Tuberculosis was frequently attributed to sexual immorality, alcohol abuse, and foul air.⁵³ Florence Nightingale was a strong proponent of the foul air theory, while the physician Sir Henry McCormack declared that the foul air explanation was, As true as the stars shine in Heaven.⁵⁴

Tuberculosis was believed to be an easy death. In 1657, Sir Thomas Browne pronounced it, One of the mercifullest executives of death, whose blows are scarce to be felt.⁵⁵ But Tolstoy had seen his brother die of it, and in Anna Karenina described a TB death: There was no position in which he was not in pain, there was not a minute that he was unconscious of it, not a limb, not a part of his body that did not ache and cause him agony.⁵⁶

With increasing urbanization, tuberculosis spiked in the 17th century; crowded conditions facilitated the spread through coughing. The philosopher John Locke, who survived a bout himself, estimated in 1667 that it caused a fifth of all deaths in London.⁵⁷ Tuberculosis mortality peaked at the end of the 18th century and through the first half of the 19th century.⁵⁸ In the United States, the peak in Boston, New York and Philadelphia was from 1812-1830.⁵⁹ An autopsy study in Paris in 1815 found that tuberculosis caused forty percent of deaths.⁶⁰ One estimate was that by 1850, three-quarters to nine-tenths of all humans were infected with TB, and that a fifth developed active disease.⁶¹

In the sparse English settlements of early America, tuberculosis was less common, although known; colonial accounts mention consumption and phthisis. In 1668, Massachusetts clergyman and physician Michael Wiggles-worth noted the death of a parishioner from a long and tedious consumption.⁶²

Looking back, F.H. Davis wrote in 1848, In the early settlements of this country, New England and the Northeast States were as free from consumption as are now the much-vaunted far-western States and Territories. It was immediately consequent upon the changes from an agricultural to a manufacturing population that the rapid increase in the death rate in consumption is apparent in these States.⁶³

In Philadelphia, Dr. Benjamin Rush noted in 1789, Phthisis… is less common in country places than in cities.⁶⁴ In the emerging cities, estimates found tuberculosis causing nineteen percent of deaths in Philadelphia one year, and fourteen percent in Salem, Massachusetts, over a decade, with similar reports from elsewhere in the colonies.⁶⁵

Tuberculosis traveled cross-country with the 49ers. A few years ago, it was supposed that the climate of California was almost proof against pulmonary disease, noted a San Francisco doctor in 1857. … Time had dispelled the delusions and Pulmonary Consumption, and its kindred affections, have be-come the great enemy of human life, as in the Atlantic States.⁶⁶

Swiftly, tuberculosis could be found virtually everywhere, with lethal footprints. In the 19th century, it became the leading cause of death in the United States, causing one out of every five deaths from 1800 to 1870.⁶⁷

In the United States, the incidence of tuberculosis increased in the 18th century…, wrote historian Gerald Grob. "Population density – and particularly housing – may well have played the most important role.⁶⁸ The lack of heating and the customs of the day of keeping doors and windows closed increased the chance of spreading the disease.

Besides devastating the urban poor, tuberculosis also carved a swath of death through the prisons of the day, notable for cramped, damp conditions and inadequate nutrition. In the United States, prisoners serving a life sentence rarely survived more than a decade, with vast numbers succumbing to TB.⁶⁹ Black prisoners did even worse; data from Pennsylvania’s Eastern State Penitentiary showed them dying at four times the rate of white prisoners.⁷⁰

As in England, America’s surge in tuberculosis from 1790 to 1840 was linked to increased urbanization, industrialization, and child labor in factories, aggravated by malnutrition.⁷¹

The flood tide of new immigrants caused them to crowd together. To house the wave of Irish immigrants, Boston tenements were remodeled to hold as many people as possible.. The average Boston dwelling squeezed up from 8.3 occupants in 1800 to 10.6 in 1845.⁷² In 1870, tuberculosis death rates in American cities were almost double those of rural areas.⁷³

One of the first large statistical analyses of health in America was the Report of the Sanitary Commission of Massachusetts in 1850, authored by Lemuel Shattuck. Shattuck, whose father had died of tuberculosis, reported that almost twenty-four percent of the fifty-seven thousand deaths in Massachusetts from 1842 to 1848 were due to tuberculosis.⁷⁴ This was more than twice the next most common cause of mortality. Shattuck, noting the relative inattention paid to this compared to epidemics, lamented, Where is the alarm and caution against (tuberculosis)… which in this state, in every day in every year deprives more than seven human beings of their life.⁷⁵

The disease was not limited to the poor and prisoners; in America, it felled Thoreau, Hawthorne, Edgar Allan Poe, Henry Clay, and George Washington’s brother Laurance.⁷⁶ Its death toll among the famous stirred a certain romanticizing of the disease. Susan Sontag observed, For more than a century and a half, tuberculosis provided a metaphoric equivalent for delicacy, sensitivity, sadness, powerlessness.⁷⁷ Thoreau’s grandfather, father and sister all preceded him in dying of tuberculosis, yet Thoreau wrote, Decay and disease are often beautiful, like… the hectic glow of consumption.⁷⁸

Tuberculosis was believed to increase artists’ and writers’ creative output. But microbiologist Rene Dubos, in his classic The White Plague, wrote, Even granted that tuberculosis can under certain circumstances stimulate spasms of creative eagerness, it is all too certain the cost is greater than the achievement.⁷⁹ Dubos adds, In the laboring classes consumption was not the aristocratic decline, stimulating works of art… It was the great killer and breeder of destitution.⁸⁰

Treatment often made things worse. When the English poet John Keats suffered two lung hemorrhages in 1820, he was treated with therapeutic bleeding; he did not long survive the disease or the treatment. Like the philosopher’s stone, a cure for consumption we apprehend to be a desideratum for ages yet to come, conceded the Boston Medical and Surgical Journal in 1843. ... Medicine has never yet accomplished it, neither has any system of regimen.⁸¹

Given the ineffectiveness of medical therapy, 19th century doctors recommended sea voyages and fresh air. The famous physician Sir William Osler wrote hopefully in 1900, An open air life sometimes cures a case of phthisis.⁸²

In an odd twist, in 19th century New England the belief developed that TB victims would return as vampires and cause consumption in others. To prevent it, TB victims’ bodies were sometimes dug up and cremated. In 1854 the Norfolk Courier described the exhumation and burning of the body of a victim dead for eight years after two of his children developed the disease.⁸³

Some managed to survive tuberculosis, including Ralph Waldo Emerson.⁸⁴ Emerson’s father, three brothers and first wife died of tuberculosis, but somehow, he lived to seventy-nine despite his tuberculosis.⁸⁵ The reason patients recovered was not well understood, and many cited psychological factors. If you want a prognosis of a case of tuberculosis, propounded Osler, it’s as important to know what’s in the patient’s head as what is in his chest.⁸⁶

To explain survival, Dubos suggested heredity, living conditions, and natural immunities, but concluded, No technique is available to identify, or measure, any of the hereditary or acquired characteristics which determine the course of tuberculosis in human beings.⁸⁷

Other diseases could worsen the prognosis. Influenza, measles and diabetes all accelerated the impact of tuberculosis.

Populations exposed to tuberculosis for the first time were hit particularly hard. Native Alaskans had been largely free of tuberculosis until the gold rush brought the disease to the Arctic. Half a century later, a government survey found ninety percent of five- and six-year-old native children infected with TB.⁸⁸ Elsewhere, first exposure also killed large numbers of Navajo and Sioux.⁸⁹

In the antebellum South, tuberculosis was the first or second largest cause of death among both blacks and whites. However, blacks were frequently struck by an aggressive form of the disease, causing severe shortness of breath, abdominal pain, rapidly progressing debility, weight loss and death, which was labeled Negro Consumption (Struma Africana). This was likely miliary tuberculosis, which affects multiple organs simultaneously. The higher frequency among slaves probably reflected poorer nutrition and medical care, as well as less prior exposure to tuberculosis.⁹⁰ Southern and Northern physicians disputed in which section consumption was worse.⁹¹

Italian physicians believed consumption to be infectious, while for centuries, the predominant opinion in northern Europe denied it. In 1680 Franciscus Sylvius wrote, It is known that this disease can be hereditary, transmitted from patients to children.⁹² In 1720 English physician Benjamin Marten was one of the rare physicians in northern Europe suggesting an infectious etiology, writing that the cause may possibly be some certain species of Animalcula or wonderfully minute living creature.⁹³

Important work in the diagnosis of tuberculosis was done by French scientist René Laennec, the early 19th century inventor of the stethoscope. Laennec concluded that the different forms of tuberculosis, striking different parts of the body, were actually a single disease.⁹⁴

In 1865 Jean Villemin, a French army doctor, noted that the horse disease glanders could be transmitted from one animal to another, and began to wonder if the same would apply for tuberculosis. In March 1865, Villemin introduced pus from TB patients into two rabbits, while inoculating two others with a placebo. Two months later, the infected rabbits had tuberculosis while the two control rabbits did not. Villemin wrote of a rabbit infected with TB, The lungs are full of large tubercles. The other (control rabbit) … did not show a single tubercle.⁹⁵ His work, which proved that tuberculosis was infectious, drew little interest, even when duplicated in the 1880s.⁹⁶

Dr. William Budd, a British physician who did pioneering epidemiological work on cholera and typhoid fever, was struck by the story of how seamen with tuberculosis, left on a tropical island, caused all the inhabitants to die of the disease. In October 1867, Budd suggested the disease was disseminated through society by specific germs in the tuberculous matter cast off by persons already suffering from the disease.⁹⁷ Dr. Joseph Benham, a prominent London physician, replied, We are not, of course, unaware of the ‘germ theory’ prevalent among the people of some Mediterranean countries, but it is lamentable to see such a figment of hot air promoted in our ‘cooler climate’.⁹⁸ Despite such statements, slow progress in understanding tuberculosis continued with the pathology of the tubercle described in 1872.

By the mid-1800s, with tuberculosis apparently as mysterious as ever, the sanatorium movement came to dominate tuberculosis treatment. Popularized by Hermann Brehmer, a German physician, it maintained that the pure air of the countryside, along with good nutrition and regular exercise, would help sufferers.⁹⁹ Brehmer observed that TB rarely occurred at altitudes above 1500 feet.¹⁰⁰ In fact, since TB flourish-es in areas of high oxygen, the lower oxygen levels at the higher altitudes may have helped check the disease. (The parallel idea that cold air helped was incorrect.) Brehmer established the first sanatorium in 1859 in Silesia, emphasizing healthy food and exercise, although many later sanatoriums substituted rest for exercise.¹⁰¹

By the 1870s, many recommended the mind cure for tuberculosis and other diseases. Writer Mark Caldwell noted the idea that for a patient, You could shift the action to your mind, convinced that aggressive optimism could heal the lungs.¹⁰² Mary Baker Eddy, founder of Christian Science, argued, Sickness, sin and death are creations of the mortal mind.¹⁰³

The pure air concept was advanced in the United States by Dr. Edward Trudeau, who nursed his older brother Francis before the latter died of tuberculosis in 1867, writing, It was my first great sorrow. It nearly broke my heart, and I have never ceased to feel its influence. In after years, it developed in me an unquenchable sympathy for all (tuberculosis) patients.¹⁰⁴ Trudeau subsequently caught tuberculosis and, in 1873, went to die amidst the Adirondack wilderness in upstate New York. Yet, Trudeau recovered, an improvement he attributed to the location. In the region, Trudeau wrote enthusiastically, diseased lungs are supplied with a specially vitalized and purified atmosphere.¹⁰⁵

In 1885, Trudeau placed five TB-infected rabbits in dark, cramped conditions, and five others on an island with abundant food, water and sunshine. While the entire first group died, four of the five rabbits on the island survived with little sign of the disease.¹⁰⁶ Trudeau’s experiment was the only real experimental evidence supporting the sanatorium movement’s philosophy of lifestyle changes, fresh air, sunshine, and good nutrition.¹⁰⁷

Trudeau decided to open a facility for tuberculosis patients in the Adirondacks, focusing on the poor. In exchange for reduced rent and medical care, the patients would serve as a test of the treatment.¹⁰⁸ Trudeau raised a large amount of money from philanthropists for the project and opened the Adirondack Cottage Sanatorium in 1884-5. He declared his goal was that poor, sick people in the cities could… have the chance of improvement I had had by coming to the Adirondacks. Eventually, the facility grew to more than twenty-two buildings, treating four thousand patients.¹⁰⁹ The principal aim of the modern sanatorium treatment of tuberculosis, explained Trudeau, is to improve the patient’s nutrition and increase his resistance to disease.¹¹⁰

But Trudeau himself was rarely free of tuberculosis symptoms, writing a friend in 1908, I am sorry to say that I am in the grasp of the enemy again.¹¹¹ Trudeau insisted, Optimism is the one thing that is within the reach of us all.¹¹² Sadly he died of TB in 1915.

U.S. sanatoriums for tuberculosis would multiply to 536 facilities treating more than 673,000 patients at its peak, yet the treatment regimen in them varied widely.¹¹³ Irving Fisher, a Yale professor and TB patient, commented in 1908, There is still no fixed theory with regard to nutrition in tuberculosis.¹¹⁴ The degree of control varied from mild, such as under Trudeau, to extremely strict. Betty McDonald, a resident at a TB sanatorium in Washington state, noted that residents there could see their children for only ten minutes a month, while spouses could visit for two hours on Thursdays and Sundays.¹¹⁵ On the theory that excitement could worsen the disease, many sanatoriums ordered patients to lie perfectly still in bed all day, forbidding talking, letter writing, reading books or news-papers, singing or laughing.¹¹⁶

While many patients showed significant gains from the treatment regimen of outdoor exercise and good nutrition, actual statistics were not impressive. Data from sanatoriums through 1940 showed that twenty-five percent of patients died there, while half the patients released died within five years.¹¹⁷ Another study of patients in New York sanatoriums from 1938-48 showed that patients with minimal disease on ad-mission did well, with seventy-eight percent having their TB still arrested after fifteen years. But of those admitted with advanced disease, fifty percent died within two years, and only twenty-seven percent had their disease arrested.¹¹⁸

One potential explanation for the benefits is that vitamin D, derived from sunlight, helps improve immune function while vitamin D deficiency degrades it. Another possibility is that the improved nutrition and generally healthier conditions in sanatoriums improved cell-mediated immunity, checking tuberculosis. Sanatoriums also improved their statistics by transferring TB patients who were not improving into facilities for incurables.¹¹⁹

In 1900 the California State Board of Health proposed banning any American with tuberculosis from entering the state. Why should this glorious state, demanded Dr. George Kober, be stocked with consumptives and their offspring?¹²⁰ Such bans were opposed as both impractical and inhumane. What one of us has not a friend or dear one who is afflicted with this disease? demanded Dr. F.M. Pittinger, president of the California Anti-Tuberculosis League. The tubercular, he argued, are not criminals.¹²¹

Many cities did create programs to incarcerate tuberculosis patients, usually the poorest, especially those who resisted treatment – although the treatments were not exactly effective.¹²²

TB was understood as a disease that isolates one from the community, wrote Sontag. It Always seemed to be a mysterious disease of individuals… that singled out its victims one by one.¹²³ Often, doctors and family members would not tell patients their condition.¹²⁴ Franz Kafka, two months before dying from tuberculosis in a Vienna sanatorium in 1924, complained, I didn’t learn anything definite in discussing TB… everyone drops into a shy evasive, glassy-eyed manner of speech.¹²⁵ In the 1880s, American doctors often advised consumptives against marriage, while the era saw an increase in abortions among tubercular women.¹²⁶

With the discovery of a specific bacterial cause came the realization that tuberculosis was infective. Increasingly governments began to track people with the disease.¹²⁷

Widespread prejudice reduced access for blacks and other minorities. Southern California, with its sunshine and temper-ate climate, attracted many TB patients to its sanatoriums. California health officials started a campaign to refuse care to immigrants, going as far as to offer to pay for transportation home for any immigrant patient with TB. Starting in 1931, and lasting until World War II, repatriation trains took almost thirteen thousand Mexican patients back to Mexico. One California physician involved in the program explained, It was a far cheaper method of caring for them than it is to allow them to stay in the County Hospital until they die.¹²⁸ Even screening for TB was slanted in favor of the wealthy, whose private physicians were not required to report the disease, while doctors in public clinics were required to report infected patients.

Tuberculosis was used to try to restrict immigration, although statistics would show that they had no higher rates than the native-born. A 1910 study of New York City residents born in Russia showed half the rate of death from tuberculosis as native-born citizens.¹²⁹ One of the biggest advocates of limitations was the impeccably named native Prescott Farnsworth Hall, Secretary of the Immigration Restriction League – who ironically died of TB at fifty-three in 1921.¹³⁰

Deaths from tuberculosis dropped dramatically in the second half of the 19th century in both Europe and the United States.¹³¹ The reasons for the decline were hotly debated. Epidemiologist Edgar Sydenstricker wrote in 1933, In no disease, as far as we know, are so many social and economic conditions involved as in tuberculosis, attributing decreased mortality to improvement in the standard of living.¹³² Wade Hampton Frost, an epidemiologist at Johns Hopkins, instead emphasized, "Progressively increasing human resistance,