The Battle against Tuberculosis: Robert Koch, the Development of TB Sanitariums, and the Enactment of Public Health Measures

Overview

During the late nineteenth century, tuberculosis, the "white plague," was the leading cause of death throughout the United States and Western Europe. Then, in 1882, a German physician named Robert Koch (1843-1910) discovered the bacterium that causes tuberculosis. With proof that the disease is caused by an infectious agent, doctors and public health officials could turn their attention toward preventing and curing it. An enormous industry sprang up around tuberculosis sanitariums—facilities where infected people would go for months or years, in the hopes that healthy living would cure them. At the same time, cities took the first steps toward implementing public health measures designed to control the spread of disease. Many of these new public health policies were controversial and unpopular, but the growth of the public health movement is credited with slowing the spread of tuberculosis throughout Europe and North America.

Background

Tuberculosis, or TB, is a bacterial disease that is spread by the respiratory route from person to person. People become infected when they breathe in air exhaled by someone with an active case of the disease. In most cases, prolonged exposure is necessary for a person to become infected. The tuberculosis bacterium can lie dormant for years. Once it becomes active, however, the bacterium infects and kills lung tissue; if the infection becomes severe enough, the patient dies.

Tuberculosis has been around at least since the Ice Age, and it exists in every region of the world; evidence of the disease has even been found in the spinal tissue of some Egyptian mummies. But there was never an epidemic like the one of the late nineteenth century. By the mid-1800s industrialization had sent throngs of people to cities across Europe and North America in search of work. Conditions in cities became crowded and the inhabitants suffered from poor nutrition, lack of hygiene, and over-work—the perfect scenario for the spread of disease. Tuberculosis spread rapidly through the packed cities and soon became epidemic. In the late 1800s about one in four people was infected with "consumption," as TB was often called. Almost every family had lost at least one member to the disease.

At the same time, there was a revolution going on in the study of diseases, especially those caused by microorganisms. In 1863 a French parasitologist named Casimir-Joseph Davaine (1812-1882) was the first to observe microscopic organisms in the blood of people suffering from certain diseases. He later observed similar organisms in the blood of sheep suffering from anthrax, a deadly disease of livestock. Davaine theorized that those organisms were in fact the cause of disease in animals and humans, but he had no proof that this was the case.

In 1876 Koch devised a method for growing the anthrax organisms in the laboratory. He then inoculated mice with these anthrax spores, and the mice became sick. Koch had proven that the microorganisms did in fact cause disease. For several years after this discovery Koch worked to perfect his methods of culturing bacteria outside of the human body; he also pioneered techniques for staining bacteria so that they could be seen under a microscope and photographed.

In 1882, convinced that tuberculosis was also caused by a microorganism, Koch turned his attention to finding it. He took samples of diseased lung tissue from tubercular patients, cultured them in a dish, and waited. Eventually the experiments worked—Koch was able to isolate and identify the bacterium that causes tuberculosis—Mycobacterium tuberculosis. In later years Koch attempted to develop a tuberculosis vaccine out of dead bacteria, which he called tuberculin, but it did not work. However, it was later discovered that an injection of tuberculin could be used to diagnose TB; when the dead bacteria are injected into an infected person, a rash develops near the site of the injection. This method of diagnosis is still used today.

Impact

Up until the time of Koch's discoveries it was widely thought that people who were infected with tuberculosis were weak or ignorant or had done something to bring the disease upon themselves; many considered it "God's will" that certain people became infected. The idea that some other organism—a germ—could make people sick had never been considered. By finding the organism that caused tuberculosis, Koch made it possible to prevent the spread of the disease and to start the search for a cure. TB was no longer God's will, it was something that could be—if not cured—at least controlled by man.

Once science and medicine accepted Koch's "germ theory," the war on germs began. Major cities, including New York, Chicago, and Philadelphia, formed the first Boards of Health. The role of the boards was to try to stop disease by halting the spread of germs—including the tuberculosis bacterium. Since there were not yet any drugs that could cure tuberculosis, officials focused on enforcing standards of hygiene and controlling the behavior of the public.

One of the most aggressive soldiers in this new public health movement was the General Medical Officer of New York City, a man named Hermann M. Biggs. Biggs believed that education and preventative health measures were the only way to fight disease. He made a map of New York City, pinpointing every single case of tuberculosis. He encouraged the disinfection of rooms where tubercular patients had stayed, started a program for registering all TB patients with the city, and he tried to require hospitals to isolate people with TB away from other patients. Biggs was praised for his thoroughness, but many of his policies were controversial. Because the poor were more susceptible to tuberculosis due to their living conditions, many viewed public health measures as a conspiracy against them. Other officials worried that strict government enforcement of health measures would turn cities into police states where sick people were considered criminals.

In 1893 Biggs established Blackwell's Island Hospital, a hospital for tuberculosis patients only, in accordance with his belief that those afflicted with TB should be kept apart from the rest of society until they recovered or died. It was not the first tuberculosis hospital—disease-specific hospitals had sprung up all over the United States and Europe starting around 1880. The treatments available to doctors were limited and low-tech, but they did what they could to help patients get stronger and stay as healthy as possible. Treatment at a tuberculosis hospital mostly involved rest, relaxation, a special diet, and a very long stay. Even if the disease was in its early stages, a minimum hospital stay of at least two years was prescribed; it often took much longer than that to get a tubercular patient healthy enough to leave. Even so, years in a hospital carried no guarantee of a cure or even long-term improvement. With no antibiotics to truly cure the disease, the most a person could hope for was some degree of healing.

While some patients were forced into urban tuberculosis hospitals, countless others were willingly fleeing to sanatoriums in the country. The first TB sanatorium was started by Edward Livingston Trudeau, a wealthy New York doctor who himself was diagnosed with tuberculosis in 1873. As his health deteriorated, Trudeau accepted that he was going to die and decided to spend his last days in the Adirondack Mountains. To his surprise, he got better. He became convinced that the climate there was the cause of his "cure," and started a sanatorium for other tuberculosis sufferers outside Saranac Lake in 1884. He started off treating just two patients, but soon the Lake Saranac Sanatorium grew to the size of a small town, with 36 buildings, including laboratories, patients' quarters, stables, and a post office.

Before long sanatoriums became a huge industry, particularly in the United States. They were built in places that seemed "healthy": on beaches, in the mountains, near lakes, in the desert. In fact, parts of the United States that were barely inhabited before suddenly boomed with the sanatorium craze; it is estimated that 60 percent of Colorado was first settled by sanatorium patients and their relatives.

No matter where they were located, all sanatoriums promised the same things—a place where tuberculosis patients could get fresh air, good food, rest, and exercise, all under the supervision of a medical staff. Like the urban TB hospitals, sanatoriums prescribed long stays—anywhere from two to 20 years. But the infected went willingly; many thought it was their last chance to recover, and often it was. But despite the resort-like setting, a stay at a sanatorium was not an extended vacation. The rules were strict and everything was regulated—when patients woke and went to bed, when and what they ate, who they spoke to, when they were allowed to go to the bathroom, even what they read. Different sanatoria had different theories on what kind of treatment would cure TB. Some swore by bizarre diets of raw eggs and cream, others believed that patients should be kept cold all the time—even making them sleep outside in winter.

Although none of those methods could be proven to restore health to tuberculosis patients, many did get well, and sanatoriums and tuberculosis hospitals proved critical to public health efforts—they took people who were sick with a contagious disease and put them in places where they couldn't spread that disease. The quarantining of patients was to be instrumental in the eventual decline of infectious tuberculosis. But while there is little doubt that the public health movement was good for society, questions still remain about how the movement affected the rights of the individual.

GERI CLARK

TUBERCULOSIS AND THE ARTS

Considering how widespread the tuberculosis epidemic was throughout Europe and North America in the nineteenth century, it is no surprise that many famous people were stricken with the disease—especially artists and writers. The list of notables who died of TB during this time includes Anton Chekhov (1904), Frederick Chopin (1849), John Keats (1821), Robert Louis Stevenson (1894), and Anne, Charlotte, and Emily Brontë (who died between 1821 and 1855).

Some philosophers and physicians of the time developed a theory that "consumption" actually sought out the artistic, and for a time TB infection became almost fashionable. It was thought of as a disease that only refined, spiritual people contracted. As the infection progressed, patients became thinner, more delicate, and more fragile, which was seen as further proof of their spirituality. Lord Byron wrote of tuberculosis: "I should like to die of consumption. The ladies would all say, 'Look at that poor Lord Byron, how interesting he looks in dying!'"

Because tuberculosis was such a part of life, it also became rich fodder for many nineteenth-century artists. In Giacomo Puccini's opera La Bohème about a group of young artists in Paris, the heroine, Mimi, collapses and dies of consumption. The title character in French author Alexandre Dumas's Camille coughs up blood and dies in the arms of her beloved, Armand. Camille is based on a real-life friend of Dumas's who died at the age of 24. The Norwegian artist Edvard Munch was greatly influenced by the deaths of his mother and older sister from tuberculosis. His paintings "The Dead Mother" and "Death in the Sickroom" are directly based on his experiences.