Dirt and Disease: Polio before FDR.

The leading cause of death in the 19th century, tuberculosis was a scourge that afflicted men, women and children of all ages, classes and geographic locations. A chronic malady characterized by a harrowing cough that occasionally gave way to terrifying hemorrhages, it caused the body to literally waste away. Often several members of a family suffered from consumption. However, doctors did not believe tuberculosis was contagious, but hereditary. In contrast, polio primarily attacked children. Though we know infantile paralysis as an epidemic disease of our own century, it existed prior to 1900, usually presenting in its nonparalytic form. Because it shared symptoms--gastrointestinal problems, fever, chills, stiff neck--with several other illnesses, it generally went unrecognized and unrecorded. Its appearance was random, striking perhaps only one child in a family with paralysis, while others were apparently left untouched. Until the end of the 19th century, however, most children infected with the virus experienced subclinical versions of polio while still infants; many developed lifelong immunity through the action of maternal antibodies.

In 1882, Robert Koch discovered the tubercle bacillus, proving that tuberculosis was communicable. Three years later, Dr. Edward Trudeau opened the first tuberculosis sanatorium in the United States, launching a radical transformation in tuberculosis treatment catalyzed by the bacteriological revolution. For the first time, scientists held out the hope of prevention and cure. Similarly, when the initial devastating epidemics of polio became increasingly virulent after the turn of the century, bacteriologists attacked this new ailment with gusto, expecting to generate knowledge of the disease's transmission and eventually produce vaccines and anti-toxins, as had been done so dramatically with smallpox, rabies, whooping cough, typhoid, diphtheria and tetanus. But polio's infecting agent was not a bacterium but a virus--as yet an unfamiliar formation too small to be seen under a common microscope and practically impossible to cultivate. Consequently, the laboratory yielded frustratingly little aid to diagnosis and therapy for much of the first half of the century. Tuberculosis, too, proved more intractable to laboratory researchers than the initial enthusiastic praise of Koch's findings had indicated. Although a skin test devised in 1907 helped track infected individuals, hopes for a cure proved elusive until the discovery of antibiotics in the 1940s.

Despite their striking epidemiological differences, the resistance of both polio and tuberculosis to swift, laboratory-produced, "magic bullet" cures makes their study particularly rewarding to historians interested in how disease is fashioned by a series of complex and delicate interactions between infection, medical treatment, public ideology, and social policy. Each of these authors argues for the social construction of illness and has brought this perspective to her book. In addition, Bates and Rogers introduce fascinating and engaging new material.

Naomi Roger's examination of epidemic polio in the years between 1900 and 1920 is full of the ironies and inconsistencies that sensitivity to the interdependence of medicine, society and culture inevitably brings into focus. Her study demonstrates the extraordinary persistence of 19th-century paradigms connecting disease with unsanitary environmental conditions and unhygienic practices even in the face of clear evidence that polio was strikingly atypical. Nineteenth-century sanitarians believed that good health was dependent on the way people lived: proper hygiene, food, fresh air, rest and exercise prevented illness. Filth, poverty, slums, overcrowding, unsanitary and dissipated personal habits, and impure sanitation facilities promoted disease. Though bacteriology altered the emphasis of public health activity, allegedly moving from a broad concern with environmental factors to a more narrow focus on individual education and treatment, cleanliness and avoiding contamination by "germs" was also a mainstay of the new approach to health. The traditional complex of attitudes, which Rogers unfortunately oversimplifies in her theme linking dirt and disease, was seriously challenged by what epidemiologists gradually learned, but for a long time refused to assimilate, about the etiology of infantile paralysis. The truth consistently denied was that improved sanitation and childcare actually contributed to the epidemics of the 20th century by removing previous pathways of early exposure and subsequent immunity generated by the less than hygienic living conditions of the past. Hence, poor, immigrant, and working-class children were still likely to develop immunity to the disease in the first two decades of the 20th century, while middle-class cleanliness put advantaged children at greater risk.

Moreover, because bacteriological research was not yet sophisticated enough to deal with the complex virology of polio--indeed research on polio played a crucial role in developing the specialty of virology--physicians learned precious little from the laboratory in terms of how to diagnose and treat the disease. Their frustrations and the idiosyncratic nature of polio's etiology led public health advocates to fall back on standard assumptions about poverty, immigrants, dirt and disease. Indeed physicians, public health officials, researchers, and progressive reformers alike seized on epidemiological models which could explain inconsistencies without challenging deep-seated assumptions. Such explanations included an emphasis on insect vectors, contaminated milk, contagious servants and other agents that might "explain" how infection was spread from the slums. Public health measures were shaped accordingly: quarantine, shutting down immigrant festivals, restricting mingling across class lines at movie houses and swimming pools, forbidding possibly infectious children from traveling out of town, attempts to remove stricken young people from homes to hospitals, massive cleanup and fly swatting campaigns, closing playgrounds and disinfecting sandpiles, and extensive public education efforts were all colored by mistaken assumptions about who was infectious and who was vulnerable. This material speaks powerfully to the ways in which culture shapes science.

Although Rogers is vivid in her portrayals of the tensions between clinicians and researchers over the failure of the laboratory to aid in treatment and the confusions and frustrations of the ordinary practitioner struggling with an intractable and mysterious disease at the bedside, she is less successful in portraying the experience of polio from the perspective of the patient. Though sensitive to the significance of the patient's voice in this story, she fails to capture it in a disappointing chapter devoted to recounting letters from the lay public written to the most prominent medical figures associated with the New York polio epidemic of 1916, including Simon Flexner of the Rockefeller Institute and Haven Emerson, Health Commissioner of New York City. Though now filed in Flexner's Papers under the heading "Crank Letters and Fantastic Theories," Rogers wants to use them to support her case that medicine is a "dynamic process of negotiation between doctor and patient within the context of family and community". Though certainly correct in her premise, Rogers fails to interpret or analyze these chaotic bits of public response, observations that run the gamut from the sublime to the ridiculous. This chapter remains a poor substitute for first-hand testimony from families--parents and children--that she might have ferreted out in order to give broader dimension to her story. Also dissatisfying is the sketchy nature of the last chapter, in which Rogers hastily accounts for the history of polio since FDR. One puzzles over the arbitrary time frame of the book and regrets the author's decision not to expand this section into full length chapters.

In contrast to the unfinished flavor of Rogers' work, Barbara Bates' volume on tuberculosis luxuriates in detail. However debatable the efficacy of her decision to limit her study to the state of Pennsylvania and the career of Dr. Lawrence Flick, who, along with Dr. Hermann M. Biggs and Dr. Edward Livingston Trudeau, probably had the most significant impact on the anti-tuberculosis movement, we have here a complex and nuanced story. Bates' work is sensitive to the entire theater on which the history of tuberculosis was acted out in these years: she describes the role of individual physicians, the medical profession, the social climate, medical research and technology, nurses, charitable and religious organizations, patients of different classes, and public health departments and administrators, examining the contribution of each in shaping response to and treatment of the disease.

Drawing on the largely unexplored manuscript collection of Flick himself, who, as an early proponent of the idea that consumption was contagious, helped organize the Pennsylvania Society for the Prevention of Tuberculosis, conducted an extensive private practice, established several sanatoria and founded a tuberculosis research institute, Bates is able to give a full account of the vagaries of the anti-tuberculosis movement in Pennsylvania from 1880 to the 1930s. Like Rogers, she is drawn to the ironies and inconsistencies of the narrative.

Unlike polio, a disease associated with improved hygiene, the image of tuberculosis was gradually transformed from a hereditary illness that could strike all social groups to an affliction gradually confined to the poor. Increasingly, epidemiological studies produced scientific evidence of the association of tuberculosis with poverty, poor nutrition, and improper housing. Yet available treatment in the 20th century did not address broad environmental solutions, but consisted primarily of the removal of infected individuals to sanatoria, visiting nurses who treated people in their homes, dispensaries devoted to education and disease management, and open air schools for sickly children. Moreover, these programs never reached the majority of the sick.

Bates's work is particularly fascinating in its analysis of the sanatorium movement. Flick shared with many other physicians and public health advocates the belief that isolating infected individuals would cure them while safeguarding their families and communities from infection. These new systems of care were in some sense subcultures of their own. Often superintendents, nurses and doctors were former consumptives. Modeled loosely on the "moral treatment" characteristic of 19th-century mental institutions, sanatoria were rigidly administered and austere. Patients found themselves "bargaining for life," often paying for their medical treatment, nursing care, room and board with their labor. Doctors gained much from the exchange, including increased knowledge and skill, clinical experience, and professional advancement.

Bates is doubtful that institutionalization accomplished its stated goals. We now know that tuberculosis mortality rates have been in decline since 1870, too early to have been much affected by the various strategies of the anti-tuberculosis movement. Bates agrees with most scholars that the primary cause of the decline has been improved standards of living, especially housing and diet. But she is rightly cautious in dismissing entirely the impact of public health campaigns. Public health education, increased attention to child and maternal welfare, changes in personal hygiene, and even the psychologically comforting effect sanatorium care may have had on the poorest patients who came from the most degraded environments, undoubtedly contributed in ways we cannot precisely measure.

Taken together, these two books offer much that is new in our understanding of the complex ways in which our century and our culture has dealt with epidemic disease. Especially instructive is how they unmask our persistent tendency to identify epidemic disease with the poor, the marginal, the deviant and the downtrodden. As living standards improved, tuberculosis increasingly became a disease of the poor. But for a while they were treated anyway, in part to insure that as servants, cooks, childkeepers, tailors and dressmakers they would not bring infection into the homes of their employers. In the case of polio, the poor were "blamed" for the epidemic. In both instances, fear of mass contagion flamed public enthusiasm for the involvement of the state and shaped its content. But as rates for contagion among the general population fell, with only the poorest of the poor still afflicted, public interest in both diseases waned. Many would argue that such patterns are repeating themselves in our present responses to AIDS. Indeed, the parallels have provided scholars and health care policy critics with much food for thought.

Regina Morantz-Sanchez University of California, Los Angeles