Tuberculosis

Tuberculosis (TB), a disease with epidemiologic, socioeconomic, and cultural significance, was long believed to be a wasting condition caused by climate, poor diet, and bad habits, but since 1882, when the German bacteriologist Robert Koch identified the tubercle bacillus, it has been understood as an infectious bacterial disease. Tuberculosis can affect animals (particularly birds and cattle) as well as human beings. It most often attacks the lungs but can also strike bones and soft tissues; though infectious, it is not epidemic.

Tuberculosis, first known as phthisis or consumption, has been recognized as a leading cause of American deaths for as long as records have been kept. Anthropological evidence suggests that it was present in Native American populations before European contact. The missionaries, surveyors, and physicians who catalogued early American disease found it so prevalent that it seemed, as one surveyor wrote, “the direct offspring of the American soil and climate.”

Tuberculosis became particularly noteworthy during the nineteenth century, when it accounted for almost a quarter of all North American deaths. Early death from tuberculosis figured prominently in the literature and popular music of the era. The disease struck all classes of Americans, but not equally. Mid‐century physicians considered race a major determinant of TB and identified African‐American slaves as particularly susceptible. After the Civil War, TB came to be seen as a particular problem of cities, with “city habits, city houses, city occupations and city life” all cited as causes. Physicians often identified women, particularly millworkers, as especially at risk. In the early twentieth century, immigrants, Native American populations, and the rural poor were thought to be particularly vulnerable. As recently as 1960, the U.S. Public Health Service described tuberculosis as “the costliest of communicable diseases,” which reflected not only the expense of screening and treatment, but also the lost wages and dependency.

As late as the mid‐twentieth century, tuberculosis was difficult to treat. Late‐nineteenth and early‐twentieth century physicians commonly advocated the sanatorium treatment, comprising rest, good diet, and exercise that Dr. Edward Livingston Trudeau (1848–1915) pioneered at Adirondack Cottage Sanatorium at Saranac Lake, New York, in 1884. Prevention, through public‐health measures, including antispitting ordinances and the disposal of infected milk and meat, became a first line of defense after Koch identified the tubercle bacillus in 1882. Voluntary associations, especially the National Tuberculosis Association, launched major educational campaigns and funded research.

Koch's identification of the tubercle bacillus inspired hopes for a vaccine, and his highly touted “tuberculin cure” (1890) aroused great optimism. But while tuberculin proved a useful diagnostic agent, it had no curative properties BCG, a vaccine developed in France in 1924, from the bacillus Calmette‐Guérin, enjoyed widespread use around the world but not in the United States. Twentieth‐century American campaigns against TB relied on public‐health measures and the antibiotic streptomycin, developed by Salman Waksman in 1943. Long‐term chemoprophylaxis with the combination of bacteriostatic agents isoniazid and PAS (para‐aminosalicylic acid) became common after 1952.

After decades of low incidence and declining visibility, tuberculosis reemerged in the 1980s as a public‐health problem. This resurgence was variously attributed to immigration, the acquired immunodeficiency syndrome (AIDS) epidemic, drug‐resistant strains of TB, urban poverty, and the absence of an adequate health and social services net.
See also Biological Sciences; Medicine: From 1776 to the 1870s; Medicine: From the 1870s to 1945; Medicine: Since 1945; Urbanization

Bibliography

Barbara Bates , Bargaining for Life: A Social History of Tuberculosis, 1876–1938, 1992.
Sheila Rothman , Living in the Shadow of Death: Tuberculosis and the Social Experience of Illness in American History, 1994.
Georgina Feldberg , Disease and Class: Tuberculosis and the Shaping of Modern North American Society, 1995.

Georgina Feldberg